造血干细胞移植后肠道移植物抗宿主病的内镜表现

Endoscopic presentation of gastrointestinal graft-versus-host disease after allogeneic hematopoietic stem cell transplantation

目的探讨异基因造血干细胞移植（allo—HSCT）后肠道移植物抗宿主病（GI—GVHD）的结肠镜下表现尤其是特征性内镜表现以及组织学活检方式。方法对比性分析36例GI-GVHD患者结直肠与回肠末端间黏膜充血、水肿、糜烂、溃疡、龟裂样改变、剥脱等内镜表现以及各肠段黏膜凋亡细胞检出率。结果结直肠和回肠末端黏膜绝大多数有异常改变（97．2％比94．1％，P=0．609）；黏膜充血多见于回肠末端（47．2％比79．4％，P=0．007），龟裂样改变主要见于结肠黏膜（63．9％比5．9％，P=0．000），黏膜水肿、糜烂和活动性出血发生率在结直肠和回肠末端相当（分别为97．2％比94．1％、80．6％比79．4％、47．2％比47．1％）。具有GI—GVHD特征性改变的黏膜剥脱可见于76．5％（26／34）的患者，在结直肠和回肠末端发生率接近（52．8％比47．1％）；结直肠黏膜剥脱周围全部伴有黏膜龟裂样改变。直肠、结肠和回肠末端黏膜凋亡细胞检出率分别为88．9％、91．3％和75．9％，回肠末端＋直肠、回肠末端＋结肠凋亡细胞检出率分别为88．2％和93．9％，只在回肠活检有可能不利于GI—GVHD的病理诊断（93．9％比75．9％，P=0．070）。结论allo—HSCT后GI—GVHD在结直肠和回肠末端的内镜表现并不一致；具有GI-GVHD特征性改变的黏膜剥脱并不少见；龟裂样改变也应是结直肠GVHD的特征性内镜表现；组织活检不应只钳取回肠末端组织，同时应活检结直肠黏膜。

Objective To investigate colonoscopic presentation and explore biopsy style of lower gastrointestinal graft-versus-host disease （GI-GVHD） after allogeneie hematopoietic stem cell transplantation （allo-HSCT）. Methods The endoscopic findings including mucosa erythema, edema, erosion, ulcer, tortoiseshell-pattern and sloughing were observed in 36 patients with GI-GVHD and the rate of apoptotic cell yields in colon and end-ileum was calculated. Results Mucosa lesions were found in almost all of the patients both in coloreetal and end-ileum （97. 2% vs 94. 1%, P =0. 609）. Mucosa erythema was more often seen in end-ileum （47.2% vs 79. 4% , P = 0. 007 ） and tortoiseshell-pattern was mainly in coloreetal mucosa （63.9% vs 5.9% , P =0. 000）. Mueosa edema, erosion and oozing bleeding were the same prevalence in large intestine and end-ileum （97.2% vs 94. 1% , 80.6% vs 79.4% , 47.2% vs 47. 1% , P 〉0.05, re- spectively）. Sloughing was found in 76. 5% （26/34） GI-GVHD patients, and it was almost the same preva- lence in large intestine and end-ileum （52. 8% vs 47. 1% , P 〉 0. 05 ）. Almost all of the coloreetal mucosa sloughing located in the tortoiseshell-pattern mucosa. Rates of apoptotic cell in rectal, colonic and end-ileal mucosa were 88.9% , 91.3% and 75.9% , respectively, and the rates were 88.2% and 93.9% in ileum plus rectum and ileum plus colon respectively, showing that biopsy only in ileum was not sufficient for the pathologic diagnosis of GI-GVHD （93.9% vs 75.9%, P = 0. 070）. Conclusion Endoscopic presentations of GI-GVHD after allo-HSCT are not the same between colorectal and end-ileal mucosa. Sloughing with GI- GVHD feature is not rarely seen in lower GI. Tortoiseshell-pattern mucosa should also be pathognomonic feature of colorectal GVHD in endoscopy. Pathologic tissue should not only be biopsied in end-ileum, but also in colorectal mucosa in the same time.