[Treatment algorithm for gastrointestinal graft-versus-host disease]

Over the last decade, there has been a dramatic decline in the frequency of organ failure, infection, and severe acute CVHD as causes of non-relapse mortality after allogeneic hematopoietic cell transplantation. Gastrointestinal CVHD, however, remains a significant obstacle to survival. Patients who present with non-progressive symptoms of the upper gut phenotype of GVHD seldom progress to severe CVHD, but may have a prolonged course, they can be successfully treated with prednisone 1 mg/kg/day for a limited time, along with topical and oral glucocorticoid. Patients who present with the mid-gut phenotype of GVHD can be recognized soon after presentation by secretory protein-losing enteropathy and falling serum albumin; their treatment requires prednisone 2 mg/kg/day and probably an additional drug such as mycophenolic acid. Failure to improve identifies a cohort with a poor prognosis; secondary therapy should be started while gut mucosa is still intact, but no secondary therapies have been proven in randomized trials to improve survival. Patients whose initial presentation (large volume diarrhea, low serum albumin, jaundice, mucosal necrosis and sloughing at initial endoscopy) presages a fatal outcome have not been studied prospectively.