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The endoscopic surveillance of the transplanted small intestine: a single center experience and a proposal for a grading score.

Journal article
Authors Jonas Varkey
Per-Ove Stotzer
Magnus Simrén
Gustaf Herlenius
Mihai Oltean
Published in Scandinavian journal of gastroenterology
Volume 53
Issue 2
Pages 134-139
ISSN 1502-7708
Publication year 2018
Published at Institute of Clinical Sciences, Department of Surgery
Institute of Medicine, Department of Internal Medicine and Clinical Nutrition
Pages 134-139
Language en
Keywords Adolescent, Adult, Aged, Biopsy, Child, Child, Preschool, Endoscopy, Gastrointestinal, Feces, chemistry, Female, Graft Rejection, diagnosis, pathology, Humans, Intestinal Mucosa, pathology, Intestine, Small, transplantation, Leukocyte L1 Antigen Complex, analysis, Male, Middle Aged, Monitoring, Physiologic, Retrospective Studies, Sensitivity and Specificity, Sweden, Young Adult
Subject categories Gastroenterology and Hepatology, Transplantation surgery


Microscopic examination of endoscopic biopsies forms the basis of acute cellular rejection (ACR) monitoring after intestinal transplantation (ITx). The endoscopy findings during acute rejection (AR) are known but a grading system for its severity is lacking. We designed and implemented a five-stage grading score based on acknowledged endoscopic features of AR, to allow a faster preliminary diagnosis of AR and intra- and interpatient comparisons.Two investigators reviewed and graded the endoscopy reports after 28 ITx using a novel score and correlated the results with pathology findings.We reviewed 512 ileoscopies: 370 examinations (74%) were normal (G0), 59 had mild alterations (erythema, edematous villi-G1) and 36 showed moderate changes (erosions, blunted villi-G2); 17 ileoscopies revealed advanced changes (ulcerations, villus loss-G3). In 18 endoscopies the changes were severe (mucosal loss-G4). Inter-reviewer agreement was very good (kappa = 0.81). Biopsies from 86 endoscopy sessions (17%) indicated ACR with 63 cases having moderate or severe ACR. For mild ACR the sensitivity of the score was 29% and the specificity was 86% whereas the positive (PPV) and negative predictive values (NPVs) were 14% and 93% respectively. During advanced ACR the sensitivity and specificity were 92% and 86%, respectively whereas the PPV and NPV were 49% and 98% respectively.Endoscopy alone has a limited ability to reliably diagnose intestinal ACR. We suggest a novel grading score summarizing ACR findings and allowing comparisons between intestinal graft endoscopies.

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