Gastro-Intestinal

Bone Marrow Transplant (BMT) Related Injury

Survivors of BMT are at increased risk of late GI toxicity from:

• Whole body radiation therapy used in conditioning regime
• Graft vs Host Disease (GvHD)
• Previous infection - such as candidiasis of the esophagus

GI toxicity is very common early after BMT, but serious long term health problems related to the intestines are relatively uncommon in this group of patients.

Chronic GI problems in BMT survivors can include:

• Xerostomia
  • Result of RT induced damage to the parotid glands
• Esophageal stricture
  • Common problem
  • Treated by dilating stricture
  • Web like intraluminal membrane forms
• Chronic GvHD involving the small intestine
  • May cause chronic diarrhoea and malabsorption
• Stasis syndrome
  • Blind loops of small intestine where bacterial overgrowth occurs
  • Loop of bowel with poor motility due to previous RT or surgery
  • Causes diarrhoea and steatorrhea
  • Malabsorption of vitamin B₁₂ may occur

Acute GvHD:

• Most commonly involves the terminal ileum and proximal colon
• Risk increased by use of pre-transplant chemotherapy and infection
• Symptoms:
  • Abdominal pain
  • Anorexia
  • Vomiting
  • Diarrhoea
  • Bleeding

Chronic GvHD:

• Starts between 3 and 12 months after transplant
• Affects about 30% of BMT survivors
• Esophagus most commonly affected (different from acute)
• Symptoms:
  • Swallowing difficulties
  • Retrosternal discomfort
  • Anorexia and weight loss
• Infection can be superimposed on to this clinical picture
• Investigation to establish the extent of upper GI tract involvement includes endoscopy.
  • Changes seen:
    • Stenosis
    • Web formation
    • Desquamation of proximal esophagus
• Pathology:
  • Loss of surface epithelium
  • Mixed acute and chronic inflammatory infiltrate
  • Necrosis of basal squamous cells
• Submucosal fibrosis causes the obstructive symptoms (not usually seen on superficial biopsy)
• Patients may need nasogastric tube/gastrostomy feeding
• Supplementation with nucleotides may be helpful

Chronic GvHD can be associated with significant malnutrition.

Reference:

National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: I. Diagnosis and Staging Working Group Report

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