Upper Versus Lower Endoscopy in the Diagnosis of Graft-Versus-Host Disease

The optimal endoscopic approach to patients with suspected gut graft-versus-host disease (GVHD) after hematopoietic stem cell transplantation (HSCT) is uncertain. We aimed to assess the diagnostic yield of upper and lower endoscopies performed in patients post-HSCT.

We identified a cohort post-HSCT with acute and chronic GVHD who underwent gastrointestinal endoscopies for GVHD diagnosis. Hospital charts were reviewed and results were stratified according to patients' symptoms.

From 1990 to 2013 433 HSCTs were performed. Fifty-six patients underwent 141 endoscopies, of which 117 were done to evaluate for GVHD or an alternative diagnosis. A total of 28/43 (65%) of the lower endoscopies and 41/74 (55%) of the upper endoscopies diagnosed GVHD or an alternative disease process on pathology. A total of 15/43 (35%) of lower endoscopies were flexible sigmoidoscopies, and 11/15 (73%) of these diagnosed GVHD or an alternative diagnosis. Upper endoscopy performed in patients with diarrhea as their only symptom diagnosed GVHD in 44% and an alternative diagnosis in 11%. In comparison, lower endoscopy in patients with only diarrhea diagnosed GVHD in 50%, and 18% offered an alternative diagnosis. Upper endoscopy provided a diagnosis of opportunistic viral and fungal infections of the upper gastrointestinal tract in 7 patients, while lower endoscopy diagnosed pseudomembranous colitis in 2.

Upper and lower endoscopy had a similar diagnostic yield in patients with known or suspected GVHD involving the gut, even for patients presenting only with diarrhea. Because of its ease and safety upper endoscopy is the preferred initial endoscopic approach in patients with suspected gut GVHD, however flexible sigmoidoscopy is a reasonable other option.