Gastrointestinal toxicity is a common early complication of allogeneic bone marrow transplants. Etiologies include mucosal damage from pretransplant conditioning, opportunistic infection, and graft-versus-host disease. Because the clinical, laboratory, radiographic, and histological findings of acute graft-versus-host disease are nonspecific, accurate diagnosis is difficult or impossible. We review the differential diagnosis of gastrointestinal complications of bone marrow transplants and implications for therapy.
den Hartog JagerF.C.; CohenP.; Van HaastertM.Late radiation injury of the rectum and sigmoid colon: Barium enema findings in 92 patients.Br. J. Radiol.62: 807–812; 1989.
9.
EmanuelD.; CunninghamI.; Jules-ElyseeK.; BrochsteinJ.A.; KernanN.A.; LaverJ.; StoverD.; WhiteD.A.; FelsA.; PolskyB.; Castro-MalaspinaH.; PeppardJ.R.; BartusP.; HammerlingU.; O'ReillyR.J.Cytomegalovirus pneumonia after bone marrow transplantation successfully treated with the combination of ganciclovir and high-dose intravenous immune globulin.Ann. Intern. Med.109: 777–782; 1988.
10.
EpsteinR.B.; McDonaldG.B.; SaleG.E.; ShulmanH.M.; ThomasE.D.The diagnostic accuracy of the rectal biopsy in acute graft-versus-host disease: A prospective study of 13 patients.Gastroenterology78: 764–771; 1980.
11.
FiskJ.D.; ShulmanH.M.; GreeningR.R.; McDonaldG.B.; SaleG.E.; ThomasE.D.Gastrointestinal radiographic features of human graft-vs.-host disease.Am. J. Roentgenol.136: 329–336; 1981.
12.
FreemanH.J.; RabeneckL.; OwenD.Survival after necrotizing enterocolitis of leukemia treated with oral vancomycin.Gastroenterology81: 791–794; 1981.
13.
GaleR.P.; BortinM.M.; van BekkumD.W.; BiggsJ.C.; DickeK.A.; GluckmanE.; GoodR.A.; HoffmannR.G.; KayH.E.M.; KerseyJ.H.; MarmontA.; MasaokaT.; RimmA.A.; van RoodJ.J.; ZwaanF.E.Risk factors of acute graft-versus-host disease.Br. J. Haematol.67: 397–406; 1987.
14.
GallucciB.B.; SaleG.E.; McDonaldG.B.; EpsteinR.; ShulmanH.M.; ThomasE.D.The fine structure of human rectal epithelium in acute graft-versus-host disease.Am. J. Surg. Pathol.6: 293–305; 1982.
15.
GlucksbergH.; StrobR.; FeferA.; BucknerC.D.; NeimanP.E.; CliftR.A.; LernerK.G.; ThomasE.D.Clinical manifestations of graft-versus-host disease in human recipients of marrow from HLA-matched sibling donors.Transplantation18: 295; 1974.
16.
HansenR.M.; ReinerioN.; SohnleP.G.; AbramsR.A.; RitchP.S.; LibnochJ.A.; AndersonT.Ketoconazole in the prevention of candidiasis in patients with cancer.Arch. Intern. Med.147: 710–712; 1987.
17.
JonesJ.M.Necrotizing Candida esophagitis. Failure of symptoms and roentgenographic findings to reflect severity.JAMA244: 2190–2191; 1980.
18.
KanojiaM.D.; AnagnostouA.A.; ZanderA.R.; VellekoopL.; SpitzerG.; VermaD.S.; JagannathS.; DickeK.A.High dose methylprednisolone treatment for acute graft-versus-host disease after bone marrow transplantation in adults.Transplantation37: 246–249; 1984.
19.
KodsiB.E.; WickremesingheP.C.; KozinnP.J.; IswaraK.; GoldbergP.K.Candida esophagitis. A prospective study of 27 cases.Gastroenterology71: 715–719; 1976.
20.
KolbH.; SaleG.E.; LernerK.G.; StorbR.; ThomasE.D.Pathology of acute graft-versus-host disease in the dog. An autopsy study of 95 dogs.Am. J. Pathol.96: 581–594; 1979.
21.
McDonaldG.B.; SaleG.E.The human gastrointestinal tract after allogeneic marrow transplantation. In: SaleG.E.; ShulmanH.M. eds. The pathology of bone marrow transplantation.New York: Masson Publishing USA, Inc.; 1984: 77–103.
22.
McDonaldG.B.; ShulmanH.M.; SullivanK.M.; SpencerG.D.Intestinal and hepatic complications of human bone marrow transplantation.Part I. Gastroenterology90: 460–477; 1986.
23.
MeiselJ.L.; PereraD.R.; MeligroC.; RubinC.E.Overwhelming watery diarrhea associated with a Cryptosporidium in an immunosuppressed patient.Gastroenterology70: 1157–1160; 1976.
24.
MowatA.M.; FelsteinM.V.Experimental studies of immunologically mediated enteropathy. V. Destructive enteropathy during an acute graft-versus-host reaction in adult BDFI mice.Clin. Exp. Immunol.79: 279–284; 1990.
25.
MurdochD.A.; GibbsS.; PriceC.G.; EasmonS.; FranklinJ.; ListerT.A.; TabaqchaliS.Effect of ceftazidine and gentamicin in the oropharyngeal and faecal flora of patients with hematological malignancies.J. Antimicrob. Chemother.26: 419–428; 1990.
26.
NashG.; RossJ.S.Herpetic esophagitis: A common cause of esophageal ulceration.Human Pathol.5: 339–345; 1974.
27.
NewburgerP.E.; CassadyJ.R.; JaffeN.Esophagitis due to adriamycin and radiation therapy for childhood malignancy.Cancer42: 417–423; 1978.
28.
NimeF.A.; BurekJ.D.; PageD.L.; HolscherM.A.; YardleyJ.H.Acute enterocolitis in a human being infected with the protozoan Cryptosporidium.Gastroenterology70: 592–598; 1976.
29.
PhillipsR.K.S.; GlazerG.; BorrielloS.P.Non-Clostridium difficile pseudomembranous colitis responding to both vancomycin and metronidazole.Br. Med. J.283: 823; 1981.
30.
PirschJ.D.; MakiD.G.Infectious complications in adults with bone marrow transplantation and T-cell depletion of donor marrow. Increased susceptibility of fungal infections.Ann. Intern. Med.104: 619–631; 1986.
31.
SaleG.E.; ShulmanH.M.; McDonaldG.B.; ThomasE.D.Gastrointestinal graft-versus-host disease in man. A clinicopathologic study of the rectal biopsy.Am. J. Surg. Pathol.3: 291–299; 1979.
32.
SaulsburyF.T.; WinkelsteinJ.A.; YolkenR.H.Chronic rotavirus infection in immunodeficiency.J. Pediatr.97: 61–65; 1980.
33.
SchillerG.J.; NimerS.D.; GajewskiJ.L.; GoldeD.W.Abdominal presentation of varicella-zoster infection in recipients of allogeneic bone marrow transplantation.Bone Marrow Transplant.7: 489–491; 1991.
34.
ShawM.T.; SpectorM.H.; LadmanA.J.Effects of cancer, radiotherapy and cytotoxic drugs on intestinal structure and function.Cancer Treat. Rev.6: 141–151; 1979.
SlavinR.E.; SantosG.W.The graft-versus-host reaction in man after bone marrow transplantation: Pathology, pathogenesis, clinical features, and implication.Clin. Immunol. Immunopathol.1: 472–498; 1973.
37.
SmithF.P.; KisnerD.L.; WiderliteA.P.; ScheinP.S.Chemotherapeutic alteration of small intestinal morphology and function: A progress report.J. Clin. Gastroenterol.1: 203–207; 1979.
38.
SullivanK.M.; KopeckyK.J.; JocomJ.; FisherL.; BucknerC.D.; MyersJ.D.; CountsG.W.; BowdenR.A.; PetersonF.B.; WitherspoonR.P.Immunomodulatory and antimicrobial efficiency of intravenous immunoglobulin in bone marrow transplantation.N. Engl. J. Med.373: 705–712; 1990.
39.
TownsendT.R.; BolyardE.A.; YolkenR.H.; BeschornerW.E.; BishopC.A.; BurnsW.H.; SantosG.W.; SaralR.Outbreak of Coxsackie A1 gastroenteritis: A complication of bone-marrow transplantation.Lancet1: 820–823; 1982.
40.
VerdonckL.F.; De GastG.G.; DekkerA.W.; De WegerR.A.; SchuurmanJ.H.; Rozenberg-ArskaM.Treatment of cytomegalovirus pneumonia after bone marrow transplantation with cytomegalovirus immunoglobulin combined with ganciclovir.Bone Marrow Transplant.4: 187–189; 1989.
41.
WeidenP.L.; Seattle Marrow Transplant Team. Graft-vs.-host disease in allogeneic marrow transplantation. In: GaleR.P.; FoxC.R. eds. Biology of bone marrow transplantation.New York: Academic Press; 1980: 37–48.
WeisdorfS.A.; LongsdorfJ.A.; SalatiL.M.; RamsayN.K.; SharpH.L.Intestinal graft-versus-host disease: A new protein losing enteropathy (abst.).Gastroenterology80: 1313; 1981.
45.
WingardJ.R.Advances in the management of infectious complications after bone marrow transplantation.Bone Marrow Transplant.6: 371–383; 1990.
WinstonD.J.; GaleR.P.Prevention and treatment of cytomegalovirus infection and disease after bone marrow transplantation in the 1990s.Bone Marrow Transplant.8: 7–11; 1991.
48.
WinstonD.J.; HoW.G.; ChamplinR.E.; GaleR.P.Infectious complications of bone marrow transplantation.Exp. Hematol.12: 205–215; 1984.
49.
WinstonD.J.; HoW.G.; LinC.H.; BartoniK.; BudingerM.D.; GaleR.P.; ChamplinR.E.Intravenous immune globulin for prevention of cytomegalovirus infection and interstitial pneumonia after bone marrow transplantation.Ann. Intern. Med.106: 12–18; 1987.
50.
WolfordJ.L.; McDonaldG.B.A problem-oriented approach to intestinal and liver disease after marrow transplantation.J. Clin. Gastroenterol.10: 419–433; 1988.
51.
WoodruffJ.M.; HansenJ.A.; GoodR.A.; SantosG.W.; SlavinR.E.The pathology of the graft-versus-host reaction (GVHR) in adults receiving bone marrow transplants.Transplant. Proc.8: 675–684; 1976.
52.
ZahradnikJ.M.; SpencerM.J.; PorterD.D.Adenovirus infection in the immunocompromised patient.Am. J. Med.68: 725–732; 1989.