[Treatment algorithm for gastrointestinal graft-versus-host disease]. / Eich gastrointestinal aguda: algoritmo de tratamiento inicial basado en datos científicos.

Over the last decade, there has been a dramatic decline in the frequency of organ failure, infection, and severe acute CVHD as causes of non-relapse mortality after allogeneic hematopoietic cell transplantation. Gastrointestinal CVHD, however, remains a significant obstacle to survival. Patients who present with non-progressive symptoms of the upper gut phenotype of GVHD seldom progress to severe CVHD, but may have a prolonged course, they can be successfully treated with prednisone 1 mg/kg/day for a limited time, along with topical and oral glucocorticoid. Patients who present with the mid-gut phenotype of GVHD can be recognized soon after presentation by secretory protein-losing enteropathy and falling serum albumin; their treatment requires prednisone 2 mg/kg/day and probably an additional drug such as mycophenolic acid. Failure to improve identifies a cohort with a poor prognosis; secondary therapy should be started while gut mucosa is still intact, but no secondary therapies have been proven in randomized trials to improve survival. Patients whose initial presentation (large volume diarrhea, low serum albumin, jaundice, mucosal necrosis and sloughing at initial endoscopy) presages a fatal outcome have not been studied prospectively.

Efficacy of neodymium:YAG laser therapy for gastric antral vascular ectasia (GAVE) following hematopoietic cell transplant.

We determined the incidence of severe bleeding from gastric antral vascular ectasia (GAVE) after myeloablative hematopoietic cell transplant and the outcomes after treatment with endoscopic neodymium:YAG laser photocoagulation. From 1992 to 2005, the incidence of severe bleeding from GAVE was 6/4491 (0.13%). All patients had received oral busulfan and four had sinusoidal obstruction syndrome. Gastrointestinal bleeding began a median of 53 days after transplant (range 15-2952). After GAVE was diagnosed by endoscopic and histologic findings, a median of three (range 2-7) sessions of laser therapy were required to control the bleeding with a median of 2737 J (range 1117-6160 J) per session. A median of 16 units (range 4-44) had been transfused prior to laser therapy and a median of four additional units (range 0-113) were transfused until bleeding was controlled. All patients were followed for at least 70 days after the last laser therapy session, with no further episodes of bleeding. Complications were mild and included abdominal pain and asymptomatic ulceration; however, one patient required gastrectomy due to gastric necrosis following transarterial embolizations. In summary, severe bleeding from GAVE is rare following hematopoietic cell transplant. Treatment with endoscopic therapy using the Nd:YAG laser is safe and effective.

Nutrient support in hematopoietic cell transplantation.

High-dose cytoreduction and hematopoietic stem cell infusion form the basis for treatment of hematologic cancers, defects or failure of hematopoiesis, and some solid tumors. As an antitumor therapy, allogeneic hematopoietic cell transplantation (HCT) is superior to autologous HCT by induction of a graft-vs-tumor effect. However, recipients of allografts suffer higher transplant-related mortality owing to graft-vs-host disease (GVHD). Nutrition support research must recognize that HCT is a heterogeneous modality whose short and long-term outcomes are affected by transplant type, preparative regimens, diagnosis, disease stage, age, and nutritional status. The field of HCT will diversify further as lower dose cytoreduction and mixed chimerism grafts allow expansion of the technique to older patients and to other diseases.