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BULLOUS ESOPHAGITIS DUE TO CHRONIC GVHD

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Dr. Minocha  is a practicing gastroenterologist and author of "Natural Stomach Care: Treating and Preventing Digestive Disorders with Best of Eastern and Western Therapies"

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Vesicles and bullae in esophagus of patients after bone marrow transplantation may occur due to infections or acute graft versus host disease (GVHD). We recently had a patient who developed a large bulla in the esophagus as a result of chronic GVHD. Bullous esophagitis due to chronic GVHD is unique.

bulletOUR CASE: A white male in his thirties presented with difficulty swallowing three years after HLA-matched sibling allogenic bone marrow transplantation.  Endoscopy of esophagus revealed

a large bulla at 25 cm from the incisor teeth. It measured approximately 5 cm in length and involved 75% of esophageal circumference. Farther to the bullous lesion, a whitish exudate could be seen. Repeat endoscopy showed a ruptured bulla Biopsies revealed fibrinopurulent exudate consistent with ulcerative esophagitis due to GVHD. There was no evidence of ground-glass multinucleated cells or inclusion bodies. Electron microscopic studies did not reveal evidence of any viral particles.

 

Stains for fungi were negative on biopsies as well as brush cytology. Cultures for viral pathogens were negative.  The patient was treated with cyclosporine A and prednisone. Anti-viral therapy was also used because of the remote possibility of infection-induced esophagitis extending into the air passages.  A follow up endoscopy one week later showed marked improvement in esophagitis and he was discharged home in a satisfactory condition.

 

 

 

DISCUSSION ON ESOPHAGUS AND CHRONIC  GRAFT  VERSUS HOST DISEASE (GVHD)

 
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ESOPHAGUS AND CHRONIC  GRAFT  VERSUS HOST DISEASE (GVHD):  One in ten patients with chronic GVHD develop problems of esophagus which appear as difficulty or painful swallowing or chest pain. Difficulty in swallowing appears as a result of narrowing of esophagus due to webs, rings or even long tapering stricture.

 
bulletPatients with pneumothorax need chest tube placement:  Management of esophageal perforation is usually surgical emergency since mortality increases with delayed surgery. On rare occasions, a self-contained leak in clinically stable patients without any evidence of infection may be managed medically. In latter case, the patient should be very carefully monitored and an extremely low threshold for surgical intervention should be employed.

 

bullet  DIFFERENTIAL DIAGNOSIS: It includes other conditions of esophagus manifesting with vescicles or bullae, e.g. vesiculobullous conditions e.g. epidermolysis bullosa, pemphigus vulgaris, benign familial pemphigus, toxic epidermal necrolysis, keratosis follicularis, herpes virus infections, bullous pemphigoid and drug reactions. Esophageal bullae may also occur as a result of endoscopy in patients otherwise at risk for bulla formation because of their skin condition.

 

bullet  TREATMENT: Drug treatment of the bullous esophagitis is basically the treatment of the cause in addition to strong acid blocking agents. Graft Versus Host Disease (GVHD) treatment includes steroids and immuno-suppressive therapy like cyclosporine. Anti-viral drugs are used if the bullae are due to viruses. Dilatation of the esophagus is required if the diameter of the esophagus is narrow.
 
 

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This is meant to be an informational exercise and NOT a medical consultation. Your doctor is the only one who can best assess your situation and offer you medical advice.

 

ABOVE INFORMATION IS BASED ON:

MINOCHA A et al.:Bullous Esophagitis Due To Chronic Graft Versus Host Disease American Journal of Gastroenterology1997

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