CT in the clinical and prognostic evaluation of acute graft-vs-host disease of the gastrointestinal tract

Objective

To determine the role of abdominal CT in assessment of severity and prognosis of patients with acute gastrointestinal (GI) graft-vs-host disease (GVHD).

Methods

During 2000–2004, 41 patients with a clinical diagnosis of acute GI-GVHD were evaluated. CTs were examined for intestinal and extra-intestinal abnormalities, and correlated with clinical staging and outcome.

Results

20 patients had GVHD clinical Stage I–II and 21 had Stage III–IV. 39 (95%) had abnormal CT appearances. The most consistent finding was bowel wall thickening: small (n=14, 34%) or large (n=5, 12%) bowel, or both (n=20, 49%). Other manifestations included bowel dilatation (n=7, 17%), mucosal enhancement (n=6, 15%) and gastric wall thickening (n=9, 38%). Extra-intestinal findings included mesenteric stranding (n=25, 61%), ascites (n=17, 41%), biliary abnormalities (n=12, 29%) and urinary excretion of orally administered gastrografin (n=12, 44%). Diffuse small-bowel thickening and any involvement of the large bowel were associated with severe clinical presentation. Diffuse small-bowel disease correlated with poor prognosis. 8 of 21 patients responded to therapy, compared with 15 of 20 patients with other patterns (p=0.02), and the cumulative incidence of GVHD-related death was 62% and 24%, respectively (p=0.01). Overall survival was not significantly different between patients with diffuse small-bowel disease and patients with other patterns (p=0.31). Colonic disease correlated with severity of GVHD (p=0.04), but not with response to therapy or prognosis (p=0.45).

Conclusion

GVHD often presented with abdominal CT abnormalities. Diffuse small-bowel disease was associated with poor therapeutic response. CT may play a role in supporting clinical diagnosis of GI GVHD and determining prognosis.Allogeneic stem-cell transplantation (SCT) has been used increasingly to treat haematopoietic disorders and haematological malignancies 1,2]. Among the complications of SCT, graft-vs-host disease (GVHD) is one of the major causes of morbidity and mortality 3-5]. Intestinal GVHD is one of the most frequent features of acute GVHD. Gastrointestinal (GI) symptoms include abdominal pain, nausea, vomiting and profuse diarrhoea 5-8]. The diagnosis and grading of the disease are based on a spectrum of clinical and laboratory features. Clinical parameters such as the quantity of diarrhoea are used to determine the clinical severity of GI GVHD 9]. These are, however, not very accurate, as assessment of the volume of diarrhoea is inconvenient and inaccurate. Endoscopic evaluation, with histological examination of biopsy specimens, can be useful for diagnosing and staging intestinal GVHD 10-12]. However, GI biopsies may be hazardous in patients with severe thrombocytopenia, coagulopathy and granulopenia 13]. Moreover, both endoscopic evaluation and histology can underestimate the severity of the disease 14].Recently, non-invasive methods have been used to assess the extent and severity of intestinal GVHD, including CT 15-20], high-resolution ultrasonography 21,22], MRI 23] and positron emission tomography with fluorodeoxyglucose (PET-FDG) 24]. Abdominal CT has been the main modality, showing abnormal findings in gastrointestinal GVHD 16,25] which correlate with both pathological 18] and clinical grading 20]. No study has as yet tried to correlate these CT findings with the outcome of the disease. This study was therefore designed to determine the role of abdominal CT in the assessment of severity and prognosis of patients with acute intestinal GVHD.