A rare cause of stricture and ulcer in the colon: Chronic graft versus host disease
Authors: COŞKUN Orhan , YILMAZ Deniz , ÖZEN Fatma , ÇAPRAZ Mustafa 
Published: August 2021

Dear Editor;

Often during routine gastroenterology examinations, ulcers and strictures in the colon and small intestine are encountered in patients. Differential diagnosis of ulcers in these patients may not always be easy. Graft-versus-host disease (GVHD) is a serious complication that can be life-threatening after allogeneic bone marrow transplantation (1). Since the introduction of modern immunosuppressive treatment regimens, clinical symptoms, radiographic and histological findings are rarely seen in chronic graft-versus-host disease (CGVHD) (2). However, CGVHD patients often present with various gastrointestinal symptoms such as esophageal reflux, dysphagia, bloating, weight loss, and diarrhea (2). Edema, erythema, diffuse polypoid lesions, multiple ulcers, and strictures in the mucosa can be observed in the endoscopic examination of intestinal GVHD (3).

We present a patient who was diagnosed with CGVHD in a colonoscopic examination performed for iron deficiency anemia.

A 52-year-old female patient was referred to our gastroenterology outpatient clinic for endoscopic examination after the laboratory tests revealed iron deficiency anemia. The patient's medical history revealed that she had undergone autologous stem cell transplantation in 2012 and allogeneic stem cell transplantation in 2016 with a diagnosis of Non-Hodgkin lymphoma. A hysterectomy had been performed due to myoma.

When the patient's complaints were questioned, there were no gastrointestinal complaints such as bloating, constipation, diarrhea, or abdominal pain. Physical examination revealed multiple psoriasis colored rashes on the skin on the neck and nape (Figure 1). White blood cell count in laboratory tests: 8920 x103/μL, platelet: 470 x103/μL, Hgb: 10.9 g/dl, aspartate aminotransferase: 47 U/L, alanine transaminase: 39 U/L, alkaline phosphatase: 99 U/L, total bilirubin: 0.56 mg/dl, albumin: 4.2 g/dL, serum iron: 115 u/dl, total iron-binding capacity: 274 u/dl, ferritin: 12 u/L, vitamin B12: 353 ng/L were detected.

The colonoscopic examination showed that, in the ascending colon, the lumen was narrowed fibrotically, not allowing the endoscope to pass proximally (Figure 2). In addition, multiple ulcerated lesions extending perpendicular to the lumen, covered with white exudate, causing shrinkage in the mucosa, and approximately 5-6 mm diameter were observed in the ascending colon, transverse colon, and descending colon (Figure 3). In the pathological examination of the biopsies taken from the lesions, the patient was diagnosed with CGVHD after intense inflammation in the lamina propria. Apoptosis in the crypts was observed, and cytomegalovirus (CMV) was excluded (Figure 4).

Endoscopic images of GVHD-induced gastrointestinal involvement vary, and the involvement of lesions may be focal or diffuse (4,5). Various lesions such as mild mucosal erythema, edema, prominent ulcers, lytic mucosal lesions can be seen in the upper and lower gastrointestinal tract (GIS) in endoscopic evaluation. The demonstration of apoptosis is very supportive for diagnosis. The diagnosis of gastrointestinal GVHD is made by endoscopic examination and mucosal biopsy, in the endoscopic biopsy (3). Other causes of apoptotic colopathy, especially CMV, should be considered in the differential diagnosis. Thus, chronic GVHD should be considered in the differential diagnosis of strictures and ulcers in a colonoscopic examination.