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Lead-pipe Colon Revisited in Chronic Graft-versus-host Disease

Saikawa, Yutaka MD, PhD; Ikawa, Yasuhiro MD; Kagaya, Takashi MD, PhD; Koizumi, Shoichi MD, PhD

Section Editor(s): Liacouras, Christopher MD; Lightdale, Jennifer R MD

Journal of Pediatric Gastroenterology & Nutrition: May 2008 - Volume 46 - Issue 5 - p 483
doi: 10.1097/MPG.0b013e3181672264
Image of the Month

Departments of Pediatrics and Internal Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan

The authors report no conflicts of interest.

A 12-year-old girl presented with a 3-day history of tarry stool and anemia. She had undergone hematopoietic stem cell transplantation with maternal grafts for acute myeloid leukemia 3 years earlier, with total body irradiation (12 Gy) for conditioning and steroids and cyclosporine for chronic extensive graft-versus-host disease (GVHD) involving the skin and lungs. Abdominal radiography revealed an air-filled, narrow descending colon with lead-pipe appearance, characterized by loss of haustral folds (Fig. 1). Emergent endoscopy identified bleeding duodenal ulcers. Colonoscopy showed diffuse mucosal scarring and loss of vascular markings in the descending colon (Fig. 2). These changes resembled a “ceramic skin” appearance. No cytomegalovirus antigenemia or infectious organisms were detected in her stools. Histological examination was not performed because the patient's condition deteriorated due to acute bleeding. Death from respiratory failure occurred due to concomitant pulmonary invasive aspergillosis.

Images in this case imply intestinal involvement by underlying chronic GVHD other than infectious colitis, due to the lack of significant pathogens in stools. However, this appearance is not specific for GVHD and diagnosis requires evaluation to exclude other potential causes. Similar intestinal changes secondary to submucosal fibrosis are observed in late-stage chronic inflammatory bowel diseases, including ulcerative colitis, Crohn disease, and colitides associated with infectious pathogens, and neutropenia, radiation, and pharmacotherapies. Radiographic findings of “lead-pipe colon” were initially described in early autopsy cases with untreated chronic GVHD. Such findings are rare in patients treated with modern immunosuppressive treatment regimens. This case thus highlights the importance of radiographic and endoscopic findings suggestive of severe involvement of the gastrointestinal tract when patients with chronic GVHD display symptoms associated with, but not specific for, involved organs.

Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

© 2008 Lippincott Williams & Wilkins, Inc.