Clin Endosc.  2024 Nov;57(6):725-734. 10.5946/ce.2024.003.

Endoscopic findings of immune checkpoint inhibitor-related gastrointestinal adverse events

• Kim MK
• Hwang SW

• KMID: 2561154
• DOI: http://doi.org/10.5946/ce.2024.003

Abstract

The use of immune checkpoint inhibitors (ICIs) for the treatment of various malignancies is increasing. Immune-related adverse events can occur after ICI administration, with gastrointestinal adverse events constituting a significant proportion of these events. When ICI-related diarrhea/colitis is suspected, endoscopic evaluation is recommended to differentiate it from other etiologies and assess the severity of colitis. The distribution of intestinal inflammation in ICI-related colitis demonstrates a high frequency of extensive colitis (23–86%). However, isolated right-sided colitis (3–8%) and ileitis (2–16%) are less prevalent. Endoscopic findings vary and predominantly encompass features indicative of inflammatory bowel disease, including aphthae, ulcers, diffuse or patchy erythema, mucosal edema, loss of vascular pattern, and friability. The presence of ulcers and extensive intestinal inflammation are associated with a reduced response to treatment. Microscopic inflammation can be observed even in endoscopically normal mucosa, underscoring the need for biopsies of seemingly normal mucosa. Histological findings present with acute/chronic inflammation and occasionally exhibit characteristics observed in inflammatory bowel disease, microscopic colitis, or ischemic colitis. The first-line therapeutic choice for ICI-related diarrhea/colitis with a common terminology criteria for adverse events grade of 2 or above is corticosteroids, whereas infliximab and vedolizumab are recommended for refractory cases.

Keyword

Drug-related side effects and adverse reactions; Endoscopy, gastrointestinal; Histology; Immune checkpoint inhibitors

Figure

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  Fig. 1. Diagnostic and management flow of immune checkpoint inhibitor-related diarrhea/colitis. ICI, immune checkpoint inhibitor; CTCAE, common terminology criteria for adverse events; IV, intravenous. Modified from Dougan et al. Gastroenterology 2021;160:1384–1393.16

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  Fig. 2. Representative images of immune checkpoint inhibitor-related endoscopic findings (The content inside the parentheses indicates histologic findings and type of immune checkpoint inhibitor used). (A) Diffuse erythematous mucosa with friability (active colitis with cryptitis, crypt abscess, crypt epithelial apoptosis and crypt drop out, anti-programmed cell death-ligand 1). (B) Aphthae and ulcer (focal active colitis with focal cryptitis and withering crypts, anti-programmed cell death protein 1). (C) Normal mucosa (mixed inflammatory cells in lamina propria with increased intraepithelial lymphocytes and microscopic colitis pattern, anti-programmed cell death-ligand 1).

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