Sa1492 Diagnostic Yield of Single Versus Double Endoscopic Examinations in Chronic Graft-Versus-Host-Disease (GVHD)

Abstract

Diagnostic Yield of Single Versus Double Endoscopic Examinations in Chronic Graft-Versus-Host-Disease (GVHD) Daena Watcha, Anne Liu, Laura Johnston, Lauren B. Gerson* Epidemiology, Stanford University, Stanford, CA; Medicine, Stanford University, Stanford, CA; Bone and Marrow Transplantation, Stanford University, Stanford, CA; Gastroenterology, Stanford University, Redwood City, CA Background: GI manifestations of chronic graft-versus-host disease (GVHD) cause significant morbidity and mortality. There has been debate regarding the utility of double versus single endoscopic examinations, optimal sites of biopsy, and whether symptoms should dictate the type of endoscopic examination performed. Methods: We performed a case-control study of 23 chronic GI-GVHD cases and 48 controls who underwent single (upper endoscopy (EGD), sigmoidoscopy (SIG), or colonoscopy (COLO)) or double (EGD plus either SIG or COLO) endoscopic procedures at least 100 days post-bone marrow transplantation between 1/2000-9/2011. We selected patients who did not have a prior diagnosis of acute GVHD, as determined by the Glucksburg criteria. Chronic GI-GVHD status was determined by the Seattle criteria. The NIH criteria were used as of 2008. Chart verification was performed to document that the patient underwent treatment with high dose steroids (corticosteroids 1 mg/kg). We collected data regarding symptoms at presentation, type of endoscopic examination performed, endoscopic findings (Cruz-Correa, Endoscopy 2002), sites of biopsy, and results of pathology examinations. Results: The GI-GVHD cases underwent 23 total endoscopic examinations including 13 (57%) double and 10 (43%) single procedures. The controls underwent 67 endoscopies including 14 (21%) double and 53 (79%) single procedures. Performance of bidirectional endoscopic examination demonstrated a positive association with diagnostic yield for chronic GVHD (p 0.001, Table 1). Symptoms leading to endoscopic examinations included diarrhea, abdominal pain, nausea, anorexia, vomiting, dysphagia, melena, failure to thrive, and GERD. The presence of diarrhea was associated with the finding of GVHD (p 0.001, Table 2). The diagnostic yield of double endoscopy alone (based on endoscopic findings without pathology) was 85% compared to 78% for lower endoscopy and 61% for EGD (p 0.3). The diagnostic yield of double endoscopy with biopsy was 92%, compared to 72% for EGD only and 83% for lower endoscopy alone (p 0.4). For the EGD examinations, biopsy at the duodenum gave the highest diagnostic yield at 92% (p 0.008 compared to gastric biopsies). In lower endoscopic examination, there was no significant difference between biopsies obtained from the right colon (terminal ileum, cecum and ascending colon, yield of 61%) and the left colon (descending colon, sigmoid and rectum, yield of 77%, p NS). Overall, 99% of patients with chronic GVHD had similar pathologic findings to those found in acute GVHD. Conclusion: The presence of diarrhea, but not nausea or abdominal pain, was positively associated with a diagnosis of chronic GVHD. The diagnostic yield was highest in patients undergoing both upper and full colonoscopic examinations with biopsies.