title: Endoscopic evaluation of small intestine transplant grafts.
abstract: BACKGROUND
  The management of small bowel transplantation is unique because signs of rejection can be obtained visually by endoscopy. The aim of this study was to evaluate the accuracy of endoscopic appearance in assessing histologic evidence of acute cellular rejection (ACR).
  
  
  METHODS
  Endoscopies were performed in 66 asymptomatic "surveillance" small bowel transplant recipients and 71 symptomatic recipients from a single center. For surveillance patients, 125 ileoscopies were performed to collect 590 biopsies, and for the symptomatic group, 229 ileoscopies and jejunoscopies were conducted to obtain 434 biopsies.
  
  
  RESULTS
  The sensitivity and specificity of endoscopic visualization in detecting ACR was 50% and 91.5% for the surveillance group and 43% and 67% for the symptomatic patients. In surveillance, visual impression alone would have missed three cases of moderate and no cases of severe ACR, whereas in the symptomatic group, visual inspection alone would have missed 20 cases of moderate ACR, and findings from visual inspection of the chimney were normal in 55% of cases with proximal ACR. However, chimney biopsy was generally representative of biopsy findings in the proximal graft but would have missed moderate to severe rejection in three patients (1%). In a subset of 23 endoscopies, zoom endoscopy did not improve visual discrimination. The only complication was a biopsy-related non-life-threatening bleed.
  
  
  CONCLUSIONS
  In symptomatic patients, visual inspection detected all cases of severe rejection but would have missed patients with early readily treatable rejection and thus making biopsy mandatory in clinical practice. Our results support the current practice of ileoscopic biopsy alone for graft surveillance in asymptomatic patients.
authors.affiliation: Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh Medical School, Pittsburgh, PA, USA. sjokeefe@pitt.edu
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: O'Keefe
authors.forename: Ihab I
authors.initials: II
authors.lastname: El Hajj
authors.forename: Tong
authors.initials: T
authors.lastname: Wu
authors.forename: Dolly
authors.initials: D
authors.lastname: Martin
authors.forename: Khaled
authors.initials: K
authors.lastname: Mohammed
authors.forename: Kareem
authors.initials: K
authors.lastname: Abu-Elmagd
mesh_terms: D000208:Acute Disease; D000328:Adult; D001706:Biopsy; D016099:Endoscopy, Gastrointestinal / Q000009:adverse effects; D005260:Female; D006084:Graft Rejection / Q000209:etiology / Q000473:pathology*; D006801:Humans; D007082:Ileum / Q000473:pathology / Q000637:transplantation*; D007583:Jejunum / Q000473:pathology / Q000637:transplantation*; D008297:Male; D008875:Middle Aged; D016377:Organ Transplantation / Q000009:adverse effects; D010414:Pennsylvania; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome