WIRELESS CAPSULE ENTEROSCPOY IN A PEDIATRIC BONE MARROW TRANSPLANT PATIENT WITH CHRONIC DIARRHEA

Abstract

Purpose: Wireless Capsule Enteroscopy (WCE) has been used in limited cases in adult patients post bone marrow transplant (BMT) as an adjunct to graft-versus-host disease (GVHD) grading. Methods: The patient is a 9-year-old male with X-linked lymphoproliferative disease. He underwent a BMT, unrelated cord blood 6/6 match, in 11/02. He had persistent watery diarrhea, GVHD stage 1–4 based on stool volumes from 500 to 2000+ cc/day, and has developed sepsis with feedings. During the last 18 months, he has undergone 7 separate endoscopic evaluations for the cause of his diarrhea. He was found to have ulcers in the colon, ranging from small apthous ulcers to larger uncerations on colonoscopies. Multiple biopsies were taken which initially demonstrated Adenovirus Antigen. Repeat biopsies 1 month later demonstrated Epstein Barr Virus DNA. Initial biopsies did not reveal GVHD on histology. After four months of anti-viral therapy and GVHD therapy, biopsies revealed grade 1–2 GVHD based on apoptotic cells and rare crypt abscess on H&E staining. He has been receiving therapy for GVHD including steroids, cyclosporin, rituximab, and rapamune, as well as anti-viral therapy, without resolution of diarrhea. He has been NPO on TPN for many months without resolution of diarrhea or colonic ulcers. A Given M2A Endoscopic Capsule was passed via EGD in 5/04 to better visualize his small bowel mucosa and determine if enteral feeds can be initiated. Results: Four small ulcers were seen in the proximal jejeunum, which were consistent with grade 1 GVHD. No lesions were identified beyond the proximal jejeunum, and the rest of the small bowel mucosa was normal in appearance. The patient tolerated the WCE procedure well, and there were no adverse results from the WCE. Following the study, oral feedings were commenced, TPN was discontinued, and the diarrhea resolved. Conclusions: In adults, there are a few case reports describing WCE use post BMT for GVHD staging. This abstract represents the first pediatric case report of WCE in a patient post BMT for GVHD staging. As a result of WCE findings showing normal appearing mucosa in the majority of the small bowel, the patient was started on enteral feeds.