This document discusses gastrointestinal and liver graft versus host disease (GVHD) in pediatric patients. It begins with an overview of GVHD, including definitions, pathogenesis, risk factors, symptoms, grading scales, and differential diagnoses for liver and GI involvement. The case presentation describes a 22 month old boy with skin and GI GVHD following a bone marrow transplant. Endoscopy findings and biopsy results are discussed which supported a diagnosis of colonic GVHD. Histologic characteristics of acute and chronic GI and liver GVHD are reviewed. Optimal biopsy sites and challenges in diagnosis are also covered.

1. Gastrointestinal and Liver
Graft Versus Host Disease (GVHD)
Peds GI
Case Conference
Joanna Yeh
9/27/2012

2. Objectives
• Discuss a case of pediatric GVHD.
• Review background on GVHD.
• Understand differential diagnosis of liver and
GI GVHD.
• Familiarize with characteristics and histologic
findings of acute and chronic GVHD.

3. Case
• 22 month old boy with familial HLH
(hemophagocytic lymphohistiocytosis).
• s/p matched, unrelated cord bone marrow
transplant on 10/24/2011.
• He had been conditioned with busulfan,
etoposide, cyclophosphamide, and ATG.
• Diagnosed with skin GVHD early on (worst on
face) and placed on solumedrol (day +1 to day
+19) and transitioned to tacrolimus and IVIg ppx.
• He had hospitalizations for skin GVHD needing
steroid pulse 4mg/kg/day in Jan 2012, Feb 2012.

4. Case
• Skin GVHD up to grade 3 (>50% BSA but no
bullae).
• He had on/off diarrhea which always
improved with increased immunosuppression
so no biopsies were obtained.
• In May 2012, he was admitted with diarrhea
(no quantification, “watery” stool “all day”).
At that time he was on prograf 0.8 mg bid and
cellcept 250 mg bid. Wt ~10kg.

5. Case
• Stool studies including c diff, campy bacterial, rota,
adeno, noro, and cells all negative.
• Medications included prograf, enalapril, cellcept,
pepcid, magnesium, fluconazole, and valycte.
• CMV and EBV PCR were negative.
• Endoscopy in May 2012 c/w colonic GVHD.
• Placed on solumedrol 4mg/kg/day and IV cellcept. He
was also put on PO budesonide and continued on IVIg.
• He was put on trophic NG feeds and TPN/IL.
• LFTs have also been elevated, thought to be from HHV6
chronic infection (liver biopsy obtained).

6. EGD: Normal
except for loss of
vascularity in
duodenum.

7. Flex sig:
Strawberry like
mucosa in rectum,
cleared by
sigmoid. Sigmoid
colon with loss of
vascularity.

8. EGD Pathology Report
• Duodenum and antrum were normal
• Mid body of stomach with mild active
inflammation. H. pylori negative.
• Overall: Not consistent with GVHD.

9. Flex Sig Pathology Report
• Sigmoid: mild active inflammation with
increased crypt apoptotic bodies, consistent
with GVHD grade 1. No PTLD or viral
inclusions.
• Rectum: moderate active inflammation with
increased crypt apoptotic bodies c/w GVHD
grade 2-3. No PTLD or viral inclusions.
• Comment: Also consider drug injury and less
likely ischemia.

10. Flex Sig Pathology Report
• There is crypt dilation, increased crypt
apoptoses, mild lamina propria neutrophilic
inflammation.
• Crypt abscesses and crypt dropout is
appreciated.
• CMV stains negative.

11. Graft vs. Host Disease (GVHD)

12. Overview
• GVHD is one of the most common complications
of hematopoietic stem cell transplant (HSCT).
• In 1955, Barnes and Loutit described diarrhea,
skin changes, and “wasting syndrome” in mice.
• Involvement can include skin, liver, GI tract, and
more rarely, lung.
• It is a leading cause of morbidity and mortality
after HSCT. It can be fatal in up to 15% of
transplant recipients.

13. Pathogenesis
• Transplanted immune cells (graft or donor)
recognize patient’s (host) cells as foreign.
• Primarily T cell mediated disease
• 3 phases
– 1: conditioning regimen damages and activates host
tissues to secrete cytokines that upregulate MHC
antigens
– 2: donor T cell activation
– 3: Multiple inflammatory cascades
• Th1 CD4 -> TNFa, IL1 -> apoptosis

14. Blazar, et al, 2012

15. When can you get GVHD?
• Hematopoietic stem cell transplant
– Non autologous (allogeneic)
– autologous
• Blood transfusion
• Solid organ transplantation
10-40% of patient develop significant (grade 2-4)
GVHD and ½ of these patients will die from
GVHD or therapy related complications

16. Definitions
• Acute: less than 100 days after transplant.
• Chronic: more than 100 days after transplant.
• But there is now a shift towards defining acute
and chronic based on clinical and histologic
manifestations.
• Hyperacute: mismatched or underprophylaxed
patients without engraftment.

17. Symptoms
• Skin rash (classically first and most common)
• Jaundice (liver is 2nd most common)
– Rarely do patients have moderate to severe hepatic GVHD
without evidence of cutaneous disease or GI disease
– Rise in direct bili and alk phos (damage to bile canaliculi,
leading to cholestasis)
• Hepatitic variant (acute transaminitis >10x)
• Diarrhea and abdominal cramping
– Watery diarrhea +/- blood
– Edema (PLE)
• Anorexia, nausea, dyspepsia, vomiting

18. Grading
Bombi, et al, 1995.

19. Differential Diagnosis
Liver
– VOD (relatively common toxicity associated with high dose
therapy or specific conditioning regimens like busulfan or cytoxan)
– Infection (most often viral hepatitis)
• CMV, EBV
• Hepatitis A, B, C
• Herpes simplex virus, HHV6
• Bacterial/fungal
– Medication
• Chemo agents
• Immunosuppressants
– CSA (cyclosporine)
– Methotrexate
– Biliary sludge/gallstones/cholecystitis
– Iron overload / hemosiderosis

20. Differential Diagnosis
Gastrointestinal
– Infection
• Clostridium difficile
• CMV*
– Antibiotic associated diarrhea
– Medication effect
• MMF (cellcept) : colitis
– Drug reaction (i.e. chemo)
– Radiation effect
– Chemotherapy effect
*Send tissue for CMV PCR / stain (characteristics overlap)
*One center routinely sent gastric and sigmoid bx for CMV and herpes simplex virus culture
Toxicity usually resolved 1 month later

22. Tuncer, et al

23. Liver: Diagnosis
• Most definitive method is biopsy.
• If not feasible (low platelets), can do transjugular
approach.
• Stains can include CMV, EBV, adenovirus, herpes
simplex virus.
• Histology:
– Bile duct atypia and degeneration (“vanishing bile
duct syndrome”)
– Epithelial cell dropout
– Lymphocytic infiltration of small bile ducts
– Severe cholestasis

24. Histology:
Hepatic GVHD
Shulman, 2006

25. GI tract: Diagnosis
• Flex sig +/- EGD (20% of pts have GVHD in upper
tract only)
• ?Colonoscopy
• Normal gross exam in up to 21% of histologically
confirmed GVHD.
• Histology:
– Crypt cell necrosis with accumulation of degenerative
material in the dead crypts
– Denuded areas with total loss of epithelium if severe
• Don’t forget to stain for CMV
Iqbal, et al, 2000
Roy, et al, 1991

26. Cruz, et al, 2002

27. Cruz, et al, 2002

28. Histology: Grading of GI tract
• Grade 1: isolated apoptotic epithelial cells
without crypt loss
• Grade 2: loss of isolated crypts without loss of
contiguous crypts; apoptosis with crypt abscess
• Grade 3: loss of 2 or more contiguous crypts;
crypt necrosis
• Grade 4: extensive crypt loss with mucosal
denudation
*grain of salt: inter-observer agreement among
pathologists is only moderate

29. Histology: Gastric GVHD
Washington, et al, 2009

30. Histology: Acute SB GVHD
Washington, et al, 2009

31. Histology: Acute Colonic GVHD
Washington, et al, 2009

32. Histology: Acute Colonic GVHD
Ross, et al, 2008

33. Optimal GI tract biopsy sites
• Not well established.
• Discordance between upper and lower tract sensitivity.
• Is GI GVHD a panintestinal process? Not always…
• Stomach more likely to show change of GVHD than
distal sites? Early on?
• Can miss up to 38% of GI GVHD if only biopsy rectum.
• Standard of care at different centers vary immensely:
pan biopsies, flex sig first, gastric first, avoid duodenum,
etc.
• Increased risk of bleeding at duodenal biopsy sites?
• Ross study (2008) in adults: rectosigmoid bx more
sensitive (retrospective).

34. Location of GI biopsies
Aslanian, 2012

35. Pediatric Data on GI GVHD
• JPGN Feb 2012
• 48 patients, single center (Wisconsin) retrospective cohort
• Common symptoms prompting endoscopy
– Diarrhea (70%)
– Nausea and vomiting (67%)
• GVHD diagnosed in 83% of patients.
• 55% patients had both upper and lower endoscopy
• Most common endoscopic finding was normal mucosa.
• Rectosigmoid and combined upper endoscopic biopsies
were equally sensitive for diagnosis of acute GVHD in
children.
• “If GVHD is found on rectosigmoid biopsy, upper endoscopy
would not be needed.”
Sultan, 2012

36. Novel biomarkers
GI
• REG3alpha (antimicrobial protein expressed in
Paneth cells)
GI & liver
• HGF (hepatocyte growth factor)
• KRT18 (cytokeratin fragment 18) – apoptotic
protein
Harris, et al

37. Chronic GVHD
• Occurs in more than 50% of long term survivors of HLA
identical sibling transplants.
• Acute GVHD has strong inflammatory component;
chronic GVHD displays more autoimmune and fibrotic
features.
• More B cell involvement. Antibodies deposit in tissues?
• Risk factors
– High recipient age
– Previous acute GVHD
– Female donor to male recipient
– CML
Blazar, et al

38. Chronic liver GVHD
• Lobular hepatitis, chronic hepatitis, reduced
or absence of small bile ducts with cholestasis.
• Pathophysiology is suggestive of primary
biliary cirrhosis.
• Portal fibrosis suggests long term persistence
of GVHD.
• Cirrhosis has been reported but is rare.

39. Chronic GI tract GVHD
• Oral mucosa: dry, ulcerations, erythematous
lesions
• Esophagus: dysphagia, ulcers, weight loss,
webs, strictures
– Esophagus usually spared in acute GVHD
• Chronic diarrhea, malabsorption, fibrosis,
sclerosis

40. Schulman, 2006

41. Washington, et al, 2009

42. Washington, et al, 2009

43. Akpek, 2003

44. Capsule Endoscopy
• Most literature in adult population.
• 1 case report of a 8 year old with large volume
bloody diarrhea.
• Diagnostic purposes to then guide treatment.

45. Treatment
• Steroids are first line (1-2 mg/kg/day)
• CSA, FK, ATG, cellcept, the list goes on…
• Infliximab is helpful in refractory GI tract
GVHD
• Oral budesonide (non absorbable) can be
helpful
• Abx? Ppx? Ciprofloxacin, rifaximin?
• Rare cases of liver tx

46. Complications with
liver biopsy and endoscopy
• Bleeding (goal plt>50)
• Hematoma (particularly duodenal?)
• Bacteremia (ppx abx if ANC<1000)
• Perforation
2006 pediatric study of 191 patients (endoscopy)
– 13 complications out of 418 procedures (3%), 8 of
which occurred in the first 100 days
Khan, et al, 2006

47. Important questions to ask:
• Date of transplant, post transplant course
• Other organ involvement of GVHD
• Conditioning regimen and immunosuppression
• R/o other diagnoses before invasive procedures
– Infection (what antivirals, antibiotics, antifungals they
are and have been on)
– Check CMV PCR
• Response of sx to increasing/decreasing
immunosuppression
• How will biopsy change management?

48. How should a pediatric
gastroenterologist called to evaluate
nonspecific GI symptoms that could
be from GVHD proceed?

49. Berquist and Dvoark, 2006

50. Summary & Conclusions
• GI and hepatic complications represent a major cause
of morbidity and mortality in pediatric BMT recipients.
• Symptoms of liver and GI GVHD are nonspecific.
• Currently, need tissue for diagnosis thus essential role
of endoscopy and liver biopsy to guide therapy.
• Chronic GVHD is not well defined, is often seen with
some type of other acute GVHD.
• Flex sig is safest and most productive method of
diagnosing GI GVHD but EGD may be needed especially
for upper GI sx (nausea, vomiting).
• Liver and GI GVHD can be difficult to diagnosis. Often,
have to exclude other causes.

51. References
• Akpek, et al, Gastrointestinal Involvement in Chronic GVHD: A Clinicopathologic Study, Biology of Blood and
Marrow Transplantation, 2003.
• Aslanian, et al, Prospective Evaluation of Acute GVHD, 2012.
• Berquist and Dvorak, Optimizing care for GI disorders in children after HSCT, Gastrointestinal Endoscopy, 2006.
• Blazar, et al, Advances in GVHD biology and therapy, Nat Rev Immunol, 2012.
• Cruz-Correa, et al, Endoscopic Findings Predict the Histologic Diagnosis in Gastrointestinal GVHD, Endoscopy,
2002.
• Harris, et al, Plasma biomarkers of lower GI and liver acute GVHD, Transplantation, 2012.
• Iqbal, et al, Diagnosis of Gastrointestinal Graft Versus Host Disease, American Journal of Gastroenterology, Nov
2000.
• Khan, et al, Diagnostic endoscopy in children after hematopoietic stem cell transplantation, Gastrointestinal
Endoscopy, 2006.
• Ma, et al, Hepatitic GVHD after HSCT, Transplantation, 2004.
• Melin-Aldana, et al, Hepatitic Pattern of GVHD in Children, Pediatr Blood Cancer, 2007.
• Ross, et al, Endoscopic Biopsy Diagnosis of Acute Gastrointestinal GVHD: Rectosigmoid biopsies are more
sensitive than upper gastrointestinal biopsies, American Journal Gastroenterology, 2008.
• Shulman, et al, Histopathologic Diagnosis of GVHD: NIH Consensus Development Project on Criteria for Clinical
Trials in Chronic GVHD, Biology of Blood and Marrow Transplantation, 2006.
• Sultan, et al, Endoscopic Diagnosis of Pediatric Acute Gastrointestinal GVHD, JPGN, 2012.
• Tuncer, et al, GI and hepatic complications of hematopoietic stem cell transplantation, World J
Gastroenterology 2012.
• Washington and Jagasia, Pathology of GVHD in the gastrointestinal tract, Human Pathology, 2009.