Specific Colonoscopic Findings of Intestinal Graft-Versus-Host Disease, Intestinal TMA, and CMV Colitis After Allogenic Hematopoietic Stem Cell Transplantaion

Abstract

Background: After allogenic hematopoietic stem cell transplantation (HSCT), significant complications involving the gastrointestinal tract occur, such as graft-versus -host disease (GVHD), thrombotic microangiopathy (TMA), and cytomegalovirus (CMV) colitis. Although the therapeutic strategies for these disorders are completely different, it is difficult to establish the differential diagnosis based on the clinical grounds alone. Little is known about the specific colonoscopic findings of these three disorders. Aim: To clarify the specific colonoscopic findings of intestinal GVHD, intestinal TMA, and CMV colitis. Patients and Methods: Between April 2001 and March 2008, 31 patients suffering from GI symptoms within the first 100 days after allogenic HSCT underwent 38 colonoscopies. The final diagnoses of these patients were made by a retrospective review of the medical records, and all 38 colonoscopic findings were analyzed. We picked up the relatively specific findings such as “spotty redness”, “sloughing of the mucosa”, “tortoiseshell pattern”, “diffuse redness”, and “punched-out ulcer” which are not usually observed in infectious colitis or inflammatory bowel diseases. To examine the diagnostic values of these colonoscopic findings, the sensitivity and, if possible, specificity of these findings for diagnosis were examined, retrospectively. Results: All 38 cases were finally diagnosed as intestinal GVHD. Eight cases were diagnosed as intestinal GVHD overlapping intestinal TMA. One case was diagnosed as intestinal GVHD overlapping CMV colitis. Spotty redness, sloughing of the mucosa, tortoiseshell pattern, diffuse redness, and punched-out ulcer were observed in 19/38 (50.0%), 29/38 (76.3%), 38/38 (100%), 7/38 (18.4%), and 1/38 (2.6%) respectively. Spotty redness, sloughing of the mucosa, and tortoiseshell pattern tended to be frequently observed in intestinal GVHD. Diffuse redness tended to be frequently observed in the cases which were diagnosed as GVHD overlapping intestinal TMA. The calculated sensitivity and specificity of this finding for the diagnosis of intestinal TMA were 75.0% and 96.8%, respectively. In only one case diagnosed as CMV colitis overlapping intestinal GVHD, multiple punched-out ulcers were detected in the descending and sigmoid colon. Conclusions: Specific colonoscopic findings may be valuable for making a differential diagnosis of intestinal GVHD, intestinal TMA, and CMV colitis after HSCT. The proposed specific findings are as follows. 1) Spotty redness, sloughing of the mucosa, and tortoiseshell pattern for intestinal GVHD. 2) Diffuse redness for intestinal TMA. 3) Punched-out ulcer for CMV colitis.