Abstract

Acute and Chronic GVHD are major complications of alloHSCT. GI GVHD can be difficult to diagnose especially early in its course or if involving the small intestine (SI). WCE is a new, noninvasive technology that allows for complete SI evaluation. The capsule transit can be measured and location tracked to determine GI hyper- or hypomotility states. We describe WCE in the diagnosis and management of GI disorders following alloHSCT. From 8/06 to 07/07, 11 alloHSCT pts with GI symptoms underwent WCE to assist in diagnosis, assess therapy response or to evaluate other GI pathology in pts with established GI acute or chronic GVHD. Pt symptoms included nausea, abdominal pain, diarrhea, vomiting and hematochezia. Concomitant studies included stool bacterial, fungal and viral cultures and C. difficile toxin assay, as well as EBV and CMV testing. Upper GI (esophagus, stomach and duodenum) and Lower GI (colon and terminal ileum) endoscopy (UGE, LGE) were performed and biopsies taken when clinically indicated. Each capsule records for 8 hours. Visual grading of the GI track was determined on a 5 point scale and labeled as Endoscopic GI Grading (EGG) (

Neumann et al
GI Endoscopy
2007
): Grade 0, normal; Grade 1, loss of vascular marking and/or mild focal erythema; Grade 2, moderate edema and/or erythema; Grade 3, edema, erythema, erosions and/or bleeding; Grade 4, ulceration, exudates and bleeding. Pts underwent WCE at a median day 77 post HSCT (range 18–593) (See Table 1). Five pts had significant gastroparesis (gastric capsule passage ≥ 2 hours), 2 of whom (pts 1, 6) had capsule stomach retention for > 8 hours. The capsule was placed in the duodenum by EGD in pt 1 with capsule passage. The cecum was not visualized in 3 pts (pts 4, 10, 11) due to delayed SI transit. WCE findings usually correlated with UGE/LGE findings but SI lesions visualized by WCE were more severe than those seen on UGE/LGE (pts 1, 5, 8, 9, 11). Repeat WCE in pt 11 demonstrated resolving lesions confirming therapy efficacy. No pt had side effects attributable to WCE and the capsule was recovered in all pts. WCE is a useful tool to diagnose and assess GI acute and chronic GVHD especially involving the SI. It is well tolerated and less invasive than UGE/LGE, making serial examinations feasible. The demonstration of delayed gastric emptying led to the use of upper GI motility agents (metoclopramide) for therapy. GI GVHD has been considered a hypermotility disorder. This study demonstrates that colonic hypermotility can occur with gastric hypomotility and that symptomatic therapy must be specific for upper and lower GI tract pathology.

Patient #UGE or LGEUGE/LGE Day post HSCTUGE/LGE EGG GradeTissue Biopsy consistent with GVHDWCE Day post HSCTWCE EGG GradeGastroparesis
UGE 212 Yes 214 2–4 Yes 
Not Done Not Done Not Done Not Done 27 2–3 No 
UGE/LGE 30 1–4 Yes 55 2–4 No 
LGE 68 2–4 Yes 99 3–4 Yes 
UGE/LGE 589 Yes 593 Yes 
UGE/LGE 37 Yes 33 3–4 Yes 
UGE/LGE 204 2–4 Yes 170 3–4 No 
LGE 15 2–3 Yes 18 3–4 No 
UGE/LGE 22 Yes 32 3–4 No 
10 UGE/LGE 16 Yes 161 Yes 
11 UGE/LGE 160 1–2 Yes 161 No 
11 Not Repeated Not Repeated Not Repeated Yes 195 3–4 No 
Patient #UGE or LGEUGE/LGE Day post HSCTUGE/LGE EGG GradeTissue Biopsy consistent with GVHDWCE Day post HSCTWCE EGG GradeGastroparesis
UGE 212 Yes 214 2–4 Yes 
Not Done Not Done Not Done Not Done 27 2–3 No 
UGE/LGE 30 1–4 Yes 55 2–4 No 
LGE 68 2–4 Yes 99 3–4 Yes 
UGE/LGE 589 Yes 593 Yes 
UGE/LGE 37 Yes 33 3–4 Yes 
UGE/LGE 204 2–4 Yes 170 3–4 No 
LGE 15 2–3 Yes 18 3–4 No 
UGE/LGE 22 Yes 32 3–4 No 
10 UGE/LGE 16 Yes 161 Yes 
11 UGE/LGE 160 1–2 Yes 161 No 
11 Not Repeated Not Repeated Not Repeated Yes 195 3–4 No 

Author notes

Disclosure: No relevant conflicts of interest to declare.