title: The Diagnostic Yield of Site and Symptom-Based Biopsies for Acute Gastrointestinal Graft-Versus-Host Disease: A 5-Year Retrospective Review.
abstract: BACKGROUND
  Graft-versus-host disease (GVHD) complicates half of hematopoietic stem cell transplants (HCT), and the gastrointestinal tract is commonly affected. Endoscopic biopsies have a key role in the diagnosis. The optimal procedure(s) to perform and site(s) to biopsy remain unclear.
  
  
  METHODS
  We retrospectively analyzed the charts of all adult patients who underwent allogeneic HCT at Duke University Medical Center between 1/1/05 and 1/1/11 and extracted data from those who underwent endoscopic biopsy for suspected GVHD. All histology was re-evaluated by blinded pathologists using 2006 NIH diagnostic criteria and then compared to the original clinical diagnosis of GVHD.
  
  
  RESULTS
  A total of 169 adult patients underwent 250 endoscopic procedures to evaluate GVHD. The sensitivity of biopsies for clinical GVHD was 76 and 72% for upper and lower tract sites, respectively. In the presence of nausea, upper tract biopsies were positive for GVHD in 65%, 70% while lower tract biopsies were positive in 61-70%. In the presence of diarrhea, lower tract biopsies were positive in 65%, while upper tract sites were positive in 64-69%. Twenty six (40%) of the sixty-five endoscopies that simultaneously sampled upper and lower tract sites had discordant results. All were histologically positive for GVHD, yet 15% of upper tract biopsies and 25% of lower tract biopsies were negative.
  
  
  CONCLUSIONS
  In this large review, the overall sensitivity of biopsies taken during EGD and Flex-Sig was 76 and 72%, respectively. A symptom-driven biopsy approach was not clearly supported as upper tract and lower tract biopsies were similarly diagnostic for GVHD regardless of symptoms.
authors.affiliation: Division of Gastroenterology, Duke University Medical Center, Durham, NC, USA. daniel.wild@duke.edu.
authors.forename: Daniel
authors.identifier: http://orcid.org/0000-0002-4968-1279
authors.initials: D
authors.lastname: Wild
authors.affiliation: Division of Hematology-Oncology, Duke Cancer Institute, Durham, NC, USA.
authors.forename: Anthony D
authors.initials: AD
authors.lastname: Sung
authors.affiliation: Division of Pathology, Duke University Medical Center, Durham, NC, USA.
authors.forename: Diana
authors.initials: D
authors.lastname: Cardona
authors.affiliation: Division of Biostatistics, Duke Cancer Institute, Durham, NC, USA.
authors.forename: Constance
authors.initials: C
authors.lastname: Cirricione
authors.affiliation: Division of Hematology-Oncology, Duke Cancer Institute, Durham, NC, USA.
authors.forename: Keith
authors.initials: K
authors.lastname: Sullivan
authors.affiliation: Division of Pathology, Duke University Medical Center, Durham, NC, USA.
authors.forename: Claire
authors.initials: C
authors.lastname: Detweiler
authors.affiliation: Division of Pathology, Duke University Medical Center, Durham, NC, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Shealy
authors.affiliation: Division of Gastroenterology, Harborview Medical Center, Seattle, WA, USA.
authors.forename: Bryan
authors.initials: B
authors.lastname: Balmadrid
authors.affiliation: Division of Hematology-Oncology, Duke Cancer Institute, Durham, NC, USA.
authors.forename: Krista L
authors.initials: KL
authors.lastname: Rowes
authors.affiliation: Division of Hematology-Oncology, Duke Cancer Institute, Durham, NC, USA.
authors.forename: Nelson
authors.initials: N
authors.lastname: Chao
authors.affiliation: Division of Hematology-Oncology, Duke Cancer Institute, Durham, NC, USA.
authors.forename: Sadhna
authors.initials: S
authors.lastname: Piryani
authors.affiliation: Division of Hematology-Oncology, Duke Cancer Institute, Durham, NC, USA.
authors.forename: Hossein Mehdikhani
authors.initials: HM
authors.lastname: Karimabad
authors.affiliation: Division of Hematology-Oncology, Duke Cancer Institute, Durham, NC, USA.
authors.forename: Paul
authors.initials: P
authors.lastname: Martin
authors.affiliation: Division of Gastroenterology, Duke University Medical Center, Durham, NC, USA.
authors.forename: Martin
authors.initials: M
authors.lastname: Poleski
mesh_terms: D000328:Adult; D000368:Aged; D001706:Biopsy; D015331:Cohort Studies; D003967:Diarrhea / Q000209:etiology; D016099:Endoscopy, Gastrointestinal; D005260:Female; D005767:Gastrointestinal Diseases / Q000150:complications / Q000175:diagnosis* / Q000473:pathology; D041981:Gastrointestinal Tract / Q000473:pathology*; D006086:Graft vs Host Disease / Q000150:complications / Q000175:diagnosis* / Q000473:pathology; D006402:Hematologic Diseases / Q000628:therapy; D019337:Hematologic Neoplasms / Q000628:therapy*; D018380:Hematopoietic Stem Cell Transplantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D009325:Nausea / Q000209:etiology; D012189:Retrospective Studies; D055815:Young Adult
keywords: Endoscopic biopsies; Graft-versus-host disease; Hematopoietic stem cell transplant; Histology