Graft versus host disease

Graft versus host disease (GvHD) is a frequent complication of allogeneic hematopoietic stem cell transplantation, commonly known as bone marrow transplantation. Anti-rejection drugs have reduced the incidence, although it does still frequently occur. 

Pathology

Graft versus host disease can present early/acute (<100 days) or late/chronic (>100 days) post-allogeneic hematopoietic stem cell transplantation and is one of the major complications of this treatment. The skin, gastrointestinal tract (especially small bowel), and liver are the principal affected organs. Effects on the gastrointestinal tract are the most commonly described in the radiology literature.

End-organ damage is the result of recipient's immune system (mainly antigen presenting cells) interacting with donor T-cell, leading to the latter's activation with a resultant cell-mediated and inflammatory cascade ⁸. The pathophysiology of chronic GvHD is not well understood.

Radiographic features

Features depend upon the organ involved.

Fluoroscopy

Gastrointestinal tract

On small bowel barium studies, the bowel is described as having a "ribbon" appearance with fold thickening. Other described features are ⁵:

• edema of mucosal folds in ileum and jejunum
• effacement of folds towards the ileum: can give featureless (atrophic) loops
• thickening of the bowel wall
• spasms and stenosis with prestenotic dilatation
• in the active phase, the bowel can appear shortened

On barium esophagram, the presence of esophageal web or of a stricture/stenosis in the upper two-thirds of the esophagus is considered diagnostic of chronic graft-versus-host disease ⁹.

CT

Abdomen

Gastrointestinal tract

Described CT features include:

• bowel wall thickening:
  • considered the most consistent finding
  • can affect small or large bowel or both (commonest ⁶)
• bowel dilatation
• mucosal enhancement
• engorgement of the vasa recta adjacent to affected bowel segments ³
• gastric wall thickening

Extraintestinal findings in the abdomen 

Reported features include:

• mesenteric stranding: ~60% ⁶
• ascites
• biliary abnormalities
• urinary excretion of orally administered Gastrografin

Thorax

See: thoracic manifestations of graft versus host disease