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Post-Transplant Complications Gastroparesis Following Bone Marrow Transplantation

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Post-Transplant Complications Gastroparesis Following Bone Marrow Transplantation Bone Marrow Transplantation (2001) 28, 59–62 2001 Nature Publishing Group All rights reserved 0268–3369/01 $15.00 www.nature.com/bmt Post-transplant complications Gastroparesis following bone marrow transplantation DA Eagle1, V Gian2, GY Lauwers1, JC Manivel3, JS Moreb1, S Mastin1 and JR Wingard1 1University of Florida College of Medicine, Gainesville, FL; 2Sarah Cannon Cancer Center, Nashville, TN; and 3University of Minnesota College of Medicine, Minneapolis, MN, USA Summary: Keywords: gastroparesis; hematopoietic cell transplant; gastric emptying; nausea and vomiting Patients often develop nausea, vomiting and bloating after bone marrow transplantation (BMT). These symp- toms may interfere with nutrition and the ability to take oral medications. Gastroparesis is a recognized cause of Following bone marrow transplantation (BMT), some these symptoms in non-transplant patients but less is patients develop persistent nausea, vomiting, bloating, early known about patients who undergo BMT. Between satiety and decreased tolerance to oral nutrition and medi- January 1996 and March 1997, a total of 151 patients cations. These symptoms frequently develop weeks after underwent BMT. Eighteen patients (12%) developed transplantation and inhibit weight gain, optimal nutrition persistent symptoms suggestive of gastroparesis and the transition from intravenous to oral medications. (persistent nausea, vomiting or bloating). Scintigraphic Gastroparesis is a disorder of motor function of the stom- gastric emptying studies were performed to assess for ach in which gastric emptying is delayed. Patients with gas- gastroparesis. Prokinetic agents were administered at troparesis often develop symptoms of nausea, vomiting, the time of study. The records on these patients were bloating and distension. Gastroparesis has many known compared with those of all other patients undergoing causes which include atrophic gastritis, diabetes, hypothy- BMT during the same time period without these symp- roidism, uremia, scleroderma, anticholinergics and stress.1 toms. Nine patients who demonstrated delayed gastric Additionally, cytomegalovirus (CMV), herpes simplex emptying were further evaluated with esophagastroduo- virus (HSV) and other viral infections have been implicated denoscopy and biopsy. Biopsy samples were reviewed as causes of delayed gastric emptying.1,2 We performed for evidence of graft-versus-host disease (GVHD). Four- gastric emptying studies on patients presenting with persist- teen of 18 patients demonstrated delayed gastric empty- ent nausea, vomiting and bloating following allogeneic or ing and most responded to prokinetic agents given at matched unrelated donor transplantation to assess for the time of study. Age, conditioning regimen, cytomega- underlying gastroparesis and to ascertain which factors lovirus antigenemia and acute GVHD did not appear were associated with the development of gastroparesis. to be associated with the development of gastroparesis. Allogeneic BMT recipients were at higher risk than autologous BMT patients (26% vs 0%, P Ͻ 0.0001). Of Methods allogeneic BMT recipients, there was a nonsignificant trend of patients receiving tacrolimus to be less likely Patients to experience gastroparesis than those receiving cyclo- sporine (27% vs 48%, P = 0.08). For the nine patients Between January 1996 and March 1997, all patients who undergoing upper endoscopy, GVHD on gastric biopsy presented after resolution of the acute toxicities of the con- was an uncommon finding and was mild when present. ditioning regimen with persistent symptoms of nausea, Gastroparesis appears to be a common cause of nausea, vomiting, bloating or early satiety at the University of Flor- vomiting and bloating following allogeneic BMT. This ida BMT clinic or inpatient unit were evaluated with Tech- may occur less often with tacrolimus than cyclosporine netium 99m-labeled egg scintigraphy. The study was per- because of the former agent’s prokinetic properties. formed by the method described by Johnson et al3 with Patients usually respond to prokinetic drugs at the time modifications by Fahey et al.4 of scintigraphy. GVHD and CMV infection do not A delay in gastric emptying was defined as a gastric emp- appear to be major contributing factors. Bone Marrow tying half-time of greater than 90 min. Intravenous erythro- Transplantation (2001) 28, 59–62. mycin and/or metochlopramide doses were frequently administered during these studies to assess their effect on gastric motility.5 A new gastric emptying half-time was Correspondence: Dr JR Wingard, Division of Hematology, University of Florida College of Medicine, 1600 SW Archer Road, PO Box 100277, determined after administration of these agents. If the slope Gainesville, FL 32610–0277, USA of the gastric emptying half-time did not change, then this Received 6 July 2000; accepted 24 January 2001 was reported as no response. Nine of the patients who were Gastroparesis following BMT DA Eagle et al 60 found to have delayed gastric emptying were further evalu- on scintography compared with those who were found to ated with esophagogastroduodenoscopy and biopsy. The have normal gastric emptying (54 vs 112 days; P = 0.011) decision to perform endoscopy was based on the rec- (Mann–Whitney U test used for calculation of differences ommendations of the consulting gastroenterologist and was with small numbers). often to look for possible infectious etiologies. Degree of the delay in gastric emptying, as well as mag- nitude of response to prokinetic agents for patients demon- Pathology strating delayed gastric emptying are given in Table 2 and illustrated in Figure 1. All 11 patients who received Biopsy samples were reviewed by pathologists at the Uni- erythromycin responded (100%), while eight of 12 patients versity of Florida and the University of Minnesota for the who received metoclopramide responded (67%). For most presence and grading of possible GVHD. All gastric patients, erythromycin accelerated gastric emptying much biopsies were fixed in buffered formalin and processed rou- more than metoclopramide. tinely. At least two hematoxylin and eosin-stained slides Nine patients with delayed gastric emptying by scinti- were reviewed for each case. The diagnosis of GVHD was graphic assessment underwent upper endoscopy. These made following the criteria put forth by Snover et al6 results are presented in Table 3. Most patients had endos- including apoptosis with karyorrhectic debris in glandular copic evidence of gastritis (n = 6) or other types of epithelium, gland destruction, dilated gastric glands con- inflammation (n = 3) on visual inspection. Two patients had taining eosinophilic granular debris and a sparse lympho- mild acute GVHD and two others had histologic findings cytic infiltrate. The degree of GVHD was quantified using suggestive of but not definitive of GVHD. None showed a three-tier grading system of mild, moderate and severe. histologic evidence of CMV or HSV gastritis. No consistent biopsy findings were apparent for patients demonstrating Data collection gastroparesis. Use of total body irradiation in the conditioning regimen, The records on all patients who underwent scintigraphic age, acute clinical GVHD at any site and CMV antigenemia assessment were subsequently reviewed. Information were not associated with the development of gastroparesis extracted from the records included patient age, time to (Table 4). Of patients developing gastroparesis, only two development of symptoms, development of acute clinical of 14 (14%) patients had undergone transplantation from GVHD at any site, conditioning regimen, immunosuppres- an unrelated donor (Table 5). Of patients not developing sive regimen, CMV antigenemia within 8 weeks of scinti- gastroparesis, 18 of 40 (45%) had undergone transplan- graphic assessment and biopsy results from endoscopy, if tation from an unrelated donor. Patients developing gastro- performed. Additionally, the records were reviewed for all paresis were less likely to have undergone transplantation other patients undergoing allogeneic and matched unrelated from an unrelated donor: 14% vs 45% (P = 0.038). Of the donor transplant during the same time period. Data 20 patients who underwent transplantation from an unre- extracted from the records for these patients included the lated donor, 16 (75%) of these patients received tacrolimus. type of conditioning regimen, immunosuppressive regimen, Of the 34 patients who underwent matched sibling trans- presence of acute clinical GVHD at any site and cytomega- plant, six (17%) received tacrolimus. Of the patients with lovirus antigenemia. gastroparesis, three of 14 (21%) received tacrolimus. Of the patients who did not develop gastroparesis, 19 of 40 (47%) received tacrolimus. There was a trend toward less gastro- Results paresis for patients receiving tacrolimus as part of the immunosuppressive regimen: 21% vs 47% (P = 0.08). A total of 151 patients aged 17 years or older underwent BMT at the University of Florida during the study period. Ninety-seven received autologous or stem cell transplan- Discussion tation, 34 received allogeneic sibling matched transplan- tation and 20 received matched unrelated donor (MUD) Following matched sibling or matched unrelated donor transplantation. Eighteen patients (12%) developed signs transplantation, patients occasionally develop persistent and symptoms suggestive of gastroparesis following trans- nausea, vomiting, bloating and lack of appetite long after plantation. Clinical characteristics and results of
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