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Table 12. Causes of Gastrointestinal (GI), Hepatobiliary, and Pancreatic Problems in Long-Term Transplant Survivorsa

Problem Areas Common Causes Less Common Causes 
Esophageal symptoms: heartburn, dysphagia, painful swallowing [31-36]Oral chronic GVHD (mucosal changes, poor dentition, xerostomia)Chronic GVHD of the esophagus (webs, rings, submucosal fibrosis and strictures, aperistalsis)
Reflux of gastric fluidHypopharyngeal dysmotility (myasthenia gravis, cricopharyngeal incoordination)
Squamous > adenocarcinoma
Pill esophagitis
Infection (fungal, viral)
Upper gut symptoms: anorexia, nausea, vomiting [37-41]Protracted acute GI GVHDSecondary adrenal insufficiency
Activation of latent infection (CMV, HSV, VZV)Acquisition of infection (enteric viruses, Giardia, cryptosporidia, Haemophilus pylori)
Medication adverse effectsGut dysmotility
Mid gut and colonic symptoms: diarrhea and abdominal pain [42,43]Protracted acute GI GVHDAcquisition of infection (enteric viruses, bacteria, parasites)
Activation of latent CMV, VZVPancreatic insufficiency
Drugs (mycophenolate mofetil, Mg++, antibiotics)Clostridium difficile colitis
Collagen-encased bowel (GVHD)
Rare: inflammatory bowel disease, sprue;[43] bile salt malabsorption; disaccharide malabsorption
Liver problems [44-54]Cholestatic GVHDHepatitic GVHD
Chronic viral hepatitis (B and C)VZV or HSV hepatitis
CirrhosisFungal abscess
Focal nodular hyperplasiaNodular regenerative hyperplasia
Nonspecific elevation of liver enzymes in serum (AP, ALT, GGT)Biliary obstruction
Drug-induced liver injury
Biliary and pancreatic problems [55-58]CholecystitisPancreatic atrophy/insufficiency
Common duct stones/sludgePancreatitis/edema, stone or sludge related
Gall bladder sludge (calcium bilirubinate)Pancreatitis, tacrolimus related
Gallstones

ALT = alanine transaminase; AP = alkaline phosphatase; CMV = cytomegalovirus; GGT = gamma glutamyl transpeptidase; HSV = herpes simplex virus; Mg++ = magnesium; VZV = varicella zoster virus.
aReprinted from Biology of Blood and Marrow Transplantation, Volume 17 (Issue 11), Michael L. Nieder, George B. McDonald, Aiko Kida, Sangeeta Hingorani, Saro H. Armenian, Kenneth R. Cooke, Michael A. Pulsipher , K. Scott Baker, National Cancer Institute–National Heart, Lung and Blood Institute/Pediatric Blood and Marrow Transplant Consortium First International Consensus Conference on Late Effects After Pediatric Hematopoietic Cell Transplantation: Long-Term Organ Damage and Dysfunction, Pages 1573–1584, Copyright 2011, with permission from American Society for Blood and Marrow Transplantation and Elsevier.[30]

References

  1. Nieder ML, McDonald GB, Kida A, et al.: National Cancer Institute-National Heart, Lung and Blood Institute/pediatric Blood and Marrow Transplant Consortium First International Consensus Conference on late effects after pediatric hematopoietic cell transplantation: long-term organ damage and dysfunction. Biol Blood Marrow Transplant 17 (11): 1573-84, 2011.  [PUBMED Abstract]

  2. Mackey JR, Desai S, Larratt L, et al.: Myasthenia gravis in association with allogeneic bone marrow transplantation: clinical observations, therapeutic implications and review of literature. Bone Marrow Transplant 19 (9): 939-42, 1997.  [PUBMED Abstract]

  3. Minocha A, Mandanas RA, Kida M, et al.: Bullous esophagitis due to chronic graft-versus-host disease. Am J Gastroenterol 92 (3): 529-30, 1997.  [PUBMED Abstract]

  4. Patey-Mariaud de Serre N, Reijasse D, Verkarre V, et al.: Chronic intestinal graft-versus-host disease: clinical, histological and immunohistochemical analysis of 17 children. Bone Marrow Transplant 29 (3): 223-30, 2002.  [PUBMED Abstract]

  5. Hockenbery DM, Cruickshank S, Rodell TC, et al.: A randomized, placebo-controlled trial of oral beclomethasone dipropionate as a prednisone-sparing therapy for gastrointestinal graft-versus-host disease. Blood 109 (10): 4557-63, 2007.  [PUBMED Abstract]

  6. Iyer RV, Hahn T, Roy HN, et al.: Long-term use of oral beclomethasone dipropionate for the treatment of gastrointestinal graft-versus-host disease. Biol Blood Marrow Transplant 11 (8): 587-92, 2005.  [PUBMED Abstract]

  7. Borgaonkar MR, Duggan PR, Adams G: Differing clinical manifestations of celiac disease transmitted by bone marrow transplantation. Dig Dis Sci 51 (1): 210-2, 2006.  [PUBMED Abstract]

  8. McDonald GB: Hepatobiliary complications of hematopoietic cell transplantation, 40 years on. Hepatology 51 (4): 1450-60, 2010.  [PUBMED Abstract]

  9. Peffault de Latour R, Lévy V, Asselah T, et al.: Long-term outcome of hepatitis C infection after bone marrow transplantation. Blood 103 (5): 1618-24, 2004.  [PUBMED Abstract]

  10. Ko CW, Murakami C, Sekijima JH, et al.: Chemical composition of gallbladder sludge in patients after marrow transplantation. Am J Gastroenterol 91 (6): 1207-10, 1996.  [PUBMED Abstract]

  11. Radu B, Allez M, Gornet JM, et al.: Chronic diarrhoea after allogenic bone marrow transplantation. Gut 54 (1): 161, 174, 2005.  [PUBMED Abstract]