Retrospective Cohort Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Oct 16, 2020; 12(10): 341-354
Published online Oct 16, 2020. doi: 10.4253/wjge.v12.i10.341
Assessing the yield and safety of endoscopy in acute graft-vs-host disease after hematopoietic stem cell transplant
Anand V Rajan, Harry Trieu, Peiguo Chu, James Lin, Trilokesh Dey Kidambi
Anand V Rajan, Harry Trieu, Peiguo Chu, James Lin, Trilokesh Dey Kidambi, Department of Medicine, City of Hope Medical Center, Duarte, CA 91010, United States
Anand V Rajan, Department of Medicine, UCLA-Olive View Medical Center, Sylmar, CA 91342, United States
Harry Trieu, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, United States
Trilokesh Dey Kidambi, Department of Gastroenterology, City of Hope, Duarte, CA 91010, United States
Author contributions: Trieu H and Rajan AV contributed equally to this work; Trieu H, Rajan AV, and Kidambi TD designed the research study with input from Lin J; Chu P performed the pathological analysis; Trieu H and Rajan AV performed the research, analyzed the data, and wrote the manuscript; all authors have read and approve the final manuscript.
Institutional review board statement: The study was reviewed and approved for publication by our Institutional Reviewer. Please see separate IRB approval form.
Informed consent statement: All study participants identities were anonymized and details that might disclose their identities were omitted. For this type of study formal consent is not required.
Conflict-of-interest statement: All the authors have no conflict of interest related to the manuscript.
Data sharing statement: The original anonymous dataset is available on request from the corresponding author at
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Trilokesh Dey Kidambi, MD, Assistant Professor, Department of Medicine, City of Hope Medical Center, 1500 E Duarte Road, Duarte, CA 91010, United States.
Received: July 22, 2020
Peer-review started: July 23, 2020
First decision: August 22, 2020
Revised: August 28, 2020
Accepted: September 8, 2020
Article in press: September 8, 2020
Published online: October 16, 2020

Acute gastrointestinal (GI) graft-vs-host disease (aGVHD) is the most complication of hematopoietic stem cell transplant (HSCT) in patients with hematologic malignancy. Limited data exists on endoscopic evaluation of GVHD in post-HSCT patients with differing GI symptoms. Further, the diagnostic value of gross endoscopic findings as well as the safety of endoscopy in this commonly thrombocytopenic and neutropenic patient population remains unclear.


To understand the diagnostic value of symptoms and gross endoscopic findings as well as safety of endoscopy in aGVHD patients.


We analyzed 195 endoscopies performed at City of Hope in patients who underwent allogeneic HSCT less than 100 d prior for hematologic malignancy and were subsequently evaluated for aGVHD via endoscopy. The yield, sensitivity, and specificity of diagnosing aGVHD were calculated for upper and lower endoscopy, various GI tract locations, and presenting symptoms.


Combined esophagogastroduodenoscopy (EGD) and flexible sigmoidoscopy (FS) demonstrated a greater diagnostic yield for aGVHD (83.1%) compared to EGD (66.7%) or FS (77.2%) alone with any presenting symptom. The upper and lower GI tract demonstrated similar yields regardless of whether patients presented with diarrhea (95.7% vs 99.1%) or nausea/vomiting (97.5% vs 96.8%). Normal-appearing mucosa was generally as specific (91.3%) as abnormal mucosa (58.7%-97.8%) for the presence of aGVHD. Adverse events such as bleeding (1.0%), infection (1.0%), and perforation (0.5%) only occurred in a small proportion of patients, with no significant differences in those with underlying thrombocytopenia (P = 1.000) and neutropenia (P = 0.425).


Combined EGD and FS with biopsies of normal and inflamed mucosa demonstrated the greatest diagnostic yield regardless of presenting symptom and appears to be safe in this population of patients.

Keywords: Graft-vs-host disease, Esophagogastroduodenoscopy, Colonoscopy, Endoscopy, Flexible sigmoidoscopy, Stem cell transplant, Hematopoietic stem cell transplant, Thrombocytopenia, Neutropenia, Malignancy

Core Tip: We analyzed a retrospective cohort of 195 endoscopies performed in cancer patients who had a hematopoietic stem cell transplant less than 100 d prior to endoscopy and evaluated the diagnostic value of various endoscopic procedures, gross endoscopic findings, and presenting symptoms. Our findings show that combined esophagogastroduodenoscopy and flexible sigmoidoscopy with biopsies of normal and abnormal-appearing mucosa results in the greatest yield for diagnosing acute gastrointestinal graft-vs-host disease independent of symptoms. Additionally, we found no significant difference in adverse events in patients with and without thrombocytopenia and neutropenia.