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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

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]


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