Persistent nausea and anorexia after marrow transplantation: a prospective study of 78 patients

Persistent nausea, vomiting, anorexia, and poor oral intake are common after hematopoietic cell transplantation. In the past, herpesvirus infections and acute intestinal graft-versus-host disease (GVHD) were the most common causes.

We studied 76 patients with 78 episodes of these symptoms to discern the causes. Diagnoses were based on histology of skin and intestinal biopsy specimens, viral cultures, and responses to therapy.

The mean day of study entry was day 57+/-31.3 posttransplant. Acute GVHD was the most common cause of symptoms, affecting 63 patients (81%) as the sole cause of symptoms and an additional 4 patients (5%) who had other concurrent causes. Patients with GVHD had marrow donors who were unrelated or HLA-mismatched in 27/63 cases. Gastric edema, erythema, and apoptotic epithelial cells were the most useful findings for the diagnosis of GVHD. Prednisone therapy (1-2 mg/kg/day) was effective in 58 of 63 patients (92%). Infection by herpes simplex virus, cytomegalovirus, or Candida was found in six patients, three of whom had concurrent GVHD. Other causes of symptoms were medications (one patients), parenteral nutrition (one patient), and sagittal sinus thrombosis (one patient).

Acute GVHD is now the dominant cause of persistent nausea and anorexia in marrow transplant patients who are beyond day 20 posttransplant. The diagnosis can be made clinically in most cases and confirmed by endoscopic biopsy of gastric mucosa. Infections, medications, and rare cases of central nervous system disease are much less common.