Pediatric Graft Versus Host Disease

  • Etiology:
    — In immune suppressed patient who is status post bone marrow transplant
    — Functionally competent introduced T-cells attack immunocompromized host cells in skin, liver, gastrointestinal tract from esophagus to rectum with small bowel always involved
  • Imaging US:
    — Small and large bowel wall thickening – mainly submucosal – especially in ileocecal region
    — Discontinuous distribution in ~ 50% helps differentiate it from typhlitis
  • Imaging CT:
    — Classically wall thickening of featureless bowel with engorgement of vasa recta and ascites
    — Generalized small bowel and large bowel thickening due to inflammation and sloughing of mucosal membranes with mucosal enhancement and submucosal enhancement – halo sign
    — Submucosal edema without perienteric stranding
    — Prominent vasa recta (comb sign)
    — Fluid-filled dilated bowel
    — Bowel can have toothpaste tube appearance
    — Ascites
    — Hepatosplenomegaly
    — Periportal edema
    — Mucosal enhancement of gallbladder and bladder
  • DDX: Typhlitis which is usually limited to cecum
  • Complications:
  • Treatment:
  • Clinical:
    — Acute graft versus host disease (GVHD) occurs up to 30 days post bone marrow transplant
    — Chronic GVHD occurs months post bone marrow transplant
    — Symptoms include abdominal pain, nausea, vomiting, severe secretory diarrhea
    — Also have classic rash and jaundice and severe mucosal inflammation
    — Usually diagnosed with skin findings and imaging often does not play a role

Radiology Cases of Graft Versus Host Disease

AXR of pneumatosis intestinalis in graft versus host disease
AXR AP shows diffuse pneumatosis intestinalis of the colon from the cecum to the rectum.
Small bowel follow through of graft versus host disease
AXR AP from a small bowel follow through shows mild thickening of the small bowel folds in the distal jejunum and proximal ileum in the middle of the image.