20 - Gastrointestinal and Hepatic Manifestations of Chronic Graft versus Host Disease

Summary

INTRODUCTION

Gastrointestinal and hepatobiliary problems are extremely common in patients with signs and symptoms of chronic GVHD elsewhere in the body, but only esophageal desquamation, webs, and submucosal fibrosis leading to strictures in the upper third of the esophagus are considered diagnostic of cGVHD per se. While a strict definition of what constitutes cGVHD is useful for research purposes, these distinctions are lost on patients whose lives are made miserable by dysphagia, persistent anorexia, nausea, vomiting, diarrhea, abdominal pain, and weight loss. This chapter reviews gastrointestinal and hepatobiliary problems in long-term survivors of allogeneic hematopoietic cell transplant according to causes of these problems (cGVHD-related, infection-related, or related to other disease processes). These categories of causes of symptoms are not mutually exclusive, as transplant survivors with gastrointestinal problems may have multiple disease processes at any one time.

ESOPHAGEAL COMPLICATIONS

Incidence

The incidence of esophageal involvement in patients with cGVHD is not known, as only patients who have esophageal symptoms undergo endoscopy. In the era of before cyclosporine, about 13% of patients with extensive chronic GVHD complained of esophageal symptoms. In some cases, esophageal cGVHD is a disease of medical neglect, or, more accurately, of undertreatment of an ongoing mucosal inflammatory process by physicians unfamiliar with cGVHD.