Colonic perforation in graft versus host disease: a case report

Diverting Enterostomy Improves Overall Survival of Patients with Severe Steroid-Refractory Gastrointestinal Acute Graft-versus-host Disease

OBJECTIVE

To evaluate the benefit of diverting enterostomy (DE) in patients with severe steroid-refractory (SR) gastrointestinal acute graft-versus-host-disease (GI-aGVHD) following allogeneic hematopoietic stem-cell transplantation (ASCT).

SUMMARY AND BACKGROUND DATA

Severe GI-aGVHD refractory to the first line steroid therapy is a rare but dramatic life-threatening complication. Second lines of immunosuppressors have limited effects and increase the risk of sepsis. Data suggest that limiting GI bacterial translocation by DE could restrain severe GI-aGVHD.

METHODS

From 2004 to 2018, we retrospectively reviewed all consecutive patients undergoing ASCT for hematologic malignancies who developed severe SR GI-aGVHD. We compared patients in whom a proximal DE was performed (Enterostomy group) with those not subjected to DE (Medical group). The primary endpoint was the 1-year overall survival (OS) measured from the onset of GI-aGVHD. Secondary endpoints were the 2-year OS and causes of death.

RESULTS

Of the 1295 patients who underwent ASCT, 51 patients with severe SR GI-aGVHD were analyzed (13 in Enterostomy group and 38 in Medical group). Characteristics of patients, transplantation modalities, and aGVHD severity were similar in both groups. The 1-year OS was better after DE (54% vs. 5%, P = 0.0004). The 2-year OS was also better in "Enterostomy group" (31% vs. 2.5%; P = 0.0015), with a trend to lower death by sepsis (30.8% vs. 57.9%; P = 0.091).

CONCLUSION

DE should be considered for severe GI-aGVHD as soon as resistance to the corticosteroid is identified.

Small Bowel Perforation Associated With Gastrointestinal Graft-Versus-Host Disease and Cytomegalovirus Enteritis in a Patient With Leukemia: A Case Report With Literature Review

Gastrointestinal graft-versus-host disease (GVHD) is a common complication after hematopoietic stem cell transplantation. Concomitant cytomegalovirus (CMV) enteritis worsens the prognosis of this condition. We report a case of small bowel perforation associated with gastrointestinal GVHD and CMV enteritis in a patient with leukemia who was successfully treated surgically. A 39-year-old man presented with intestinal perforation necessitating emergency surgical intervention. He was diagnosed with T-cell acute lymphoblastic leukemia and developed severe gastrointestinal GVHD and CMV enteritis after hematopoietic stem cell transplantation. His terminal ileum showed a perforation with diffuse wall thinning, and petechiae were observed over long segments of the distal ileum and the proximal colon. Small bowel segmental resection and a subtotal colectomy with a double-barreled ileocolostomy were performed. The patient recovered uneventfully after the operation. Based on reports described in the literature, surgery plays a minor role in the management of gastrointestinal GVHD; however, timely surgical intervention could be effective in selected patients.

Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Graft- versus -host disease

The Brazilian Consensus on Nutrition in Hematopoietic Stem Cell Transplantation: Graft- versus -host disease was approved by Sociedade Brasileira de Transplante de Medula Óssea , with the participation of 26 Brazilian hematopoietic stem cell transplantation centers. It describes the main nutritional protocols in cases of Graft- versus -host disease, the main complication of hematopoietic stem cell transplantation.

Intestinal thrombotic microangiopathy: a distinct entity in the spectrum of graft-versus-host disease

Transplant-associated thrombotic microangiopathy (TA-TMA) is a severe complication of allogeneic hematopoietic cell transplantation (allo-HCT) with multisystem involvement. Cases of TMA in the intestinal vasculature (intestinal TMA/iTMA) have been reported. We hypothesized that iTMA is a distinct entity from TA-TMA. To test this hypothesis, we prospectively recruited allo-HCT recipients with an indication for endoscopy. Among 20 patients, histological features of iTMA, including loss of glands, total denudation of mucosa, apoptosis and detachment of endothelial cells, mucosal hemorrhage, intraluminal fibrin and microthrombi were found in six. Only 2/6 were classified as GVHD/TA-TMA, while the other 4 as GVHD/no TA-TMA. Gastro-intestinal symptoms were similar between the patients with or without iTMA. With a median follow-up of 11.1 (2.1-67.5) months, 1-year overall survival was 22.2% for iTMA, 55% for GVHD and 60% for TA-TMA. On multivariate analysis, independent unfavorable predictors of OS were iTMA (p = 0.048), HLA mismatched donors (p = 0.008) and gastro-intestinal bleeding (p = 0.021). In conclusion, iTMA emerges as a novel distinct entity in patients with GVHD and/or TA-TMA. Distinct histological features may be useful in differential diagnosis of these severe HCT complications. The higher mortality rates of iTMA than TA-TMA highlight the need for further investigation of this condition.

Surgical treatment of intestinal complications of graft versus host disease in the pediatric population: Case series and review of literature

BACKGROUND/PURPOSE

Intestinal complications of acute graft-versus-host disease (aGVHD) include hemorrhage and perforation in the short-term, and stricture with bowel obstruction in the long-term. As medical management of severe aGVHD has improved, more patients are surviving even advanced stages of intestinal aGVHD. This review summarizes the available pediatric literature on surgical treatment of complications of intestinal GVHD.

METHODS

A systematic review was performed using PubMed, Cochrane, Embase, and Scopus databases. Any publication that addressed surgical treatment of acute and chronic intestinal GVHD in the pediatric population was reviewed in detail. Furthermore, we included information on 5 additional patients from the institutions of this review's authors, which had not been previously published.

RESULTS

We identified 8 studies, comprising 13 patients. Surgical interventions were undertaken for a variety of intestinal GVHD complications, including small bowel obstruction owing to stricture (n=8), enterocutaneous fistulae (n=2), gastrointestinal hemorrhage/perforation (n=1 each), and esophageal stricture (n=1). Among eight patients with bowel obstruction as an indication, pathology revealed ulceration with fibrosis in all but one; 3 had signs of persistent GVHD. Surgical mortality was reported in 4 patients (31%) at an average of 6weeks postoperatively. The median overall follow-up time was 20months (IQR, 2-21).

CONCLUSIONS

Although intestinal aGVHD management is almost exclusively medical, a small subset of patients develops complications of intestinal GVHD that require surgical intervention. With expanding indications for stem cell transplantation as well as improved survival after previously fatal bouts of intestinal aGVHD, it is likely that surgical intervention will become more common in these complicated patients.

SYSTEMATIC REVIEW

Level of Evidence: Level IV.

Selected Topics in Anaerobic Bacteriology

Alteration in the host microbiome at skin and mucosal surfaces plays a role in the function of the immune system, and may predispose immunocompromised patients to infection. Because obligate anaerobes are the predominant type of bacteria present in humans at skin and mucosal surfaces, immunocompromised patients are at increased risk for serious invasive infection due to anaerobes. Laboratory approaches to the diagnosis of anaerobe infections that occur due to pyogenic, polymicrobial, or toxin-producing organisms are described. The clinical interpretation and limitations of anaerobe recovery from specimens, anaerobe-identification procedures, and antibiotic-susceptibility testing are outlined. Bacteriotherapy following analysis of disruption of the host microbiome has been effective for treatment of refractory or recurrent Clostridium difficile infection, and may become feasible for other conditions in the future.

Intestinal ischemia after allogeneic stem cell transplantation: a report of four cases

Gastrointestinal ischemia after allogeneic bone marrow transplantation is a rare complication not well-described in the literature. Herein we retrospectively review charts of four patients who developed intestinal ischemia after allogeneic bone marrow transplantation at our institution. The patients were found to be predominately younger males who presented with nonspecific abdominal pain. Graft-versus-host disease was a common finding among all patients. Laboratory values suggestive of microangiopathy were present in two patients. Obesity and hypertriglyceridemia were cardiovascular risk factors found in these patients. The development of thrombotic microangiopathy and cardiovascular risk factors after allogeneic bone marrow transplantation may predispose patients to gastrointestinal ischemia and may portend a poor prognosis.