Graft versus host disease

Topic Completed: 1 August 2017

Minor changes: 26 January 2021

Copyright: 2002-2021,, Inc.

PubMed Search: Gastric (graft versus host disease [title])

Natalya Shlyakhova, M.D.
Page views in 2020: 3,342
Page views in 2021 to date: 1,359
Cite this page: Shlyakhova N, Lu Y. Graft versus host disease. website. Accessed May 8th, 2021.
Definition / general
Clinical features
  • Histologic criteria (grading) originally described in 1975 by Lerner et al. includes 4 histological grades for the GI biopsies (Transplant Proc 1974;6:367, Ann Intern Med 1994;120:143):

      Organ Involvement
    Grade Skin Liver Gut
    I Epidermal, basal cell, vacuolar degeneration < 25% small interlobular bile ducts abnormal (degeneration or necrosis) Single cell necrosis of epithelial cells
    II Grade I changes plus "eosinophilic bodies" 25% to 50% bile ducts abnormal Necrosis and loss of glands
    III Grade II changes plus separation of the dermal epidermal junction 50% to 75% bile ducts abnormal Focal microscopic mucosal denudation
    IV Frank epidermal denudation > 75% bile ducts abnormal Diffuse mucosal denudation

  • Currently, NIH consensus criteria incorporate timing of the presentation and clinical findings in addition to histologic criteria:
    • Classic acute GVHD: cases present within 100 days of HCT and display features of acute GVHD; diagnostic and distinctive features of chronic GVHD are absent
    • Persistent, recurrent, late onset acute GVHD: cases present greater than 100 days post-HCT with features of acute GVHD; diagnostic and distinctive features of chronic GVHD are absent
    • Classic chronic GVHD: cases may present at any time post-HCT; diagnostic and distinctive features of chronic GVHD are present and there are no features of acute GVHD
    • Overlap syndrome: cases may present at any time post-HCT with features of both chronic GVHD and acute GVHD; on occasion, this is colloquially referred to as "acute on chronic" GVHD (UpToDate: Clinical Manifestations, Diagnosis and Grading of Acute Graft Versus Host Disease [Accessed 1 August 2018])
  • Diagnosis of chronic GVHD requires the presence of at least one diagnostic clinical sign of chronic GVHD or the presence of at least one distinctive manifestation confirmed by pertinent biopsy or other relevant tests in the same or another organ
  • Pathology report recommendation:
    • All pathology reports should report both histologic features and a final diagnosis
    • Final diagnosis integrates the histopathologic results and the clinical context and is summarized in 1 of 4 categories:
Endoscopy findings
Prognostic factors
Case reports
  • Steroids, mycophenolate mofetil, tacrolimus, cyclosporine, infliximab, daclizumab
Microscopic (histologic) description
Microscopic (histologic) images

Contributed by Heidi D. Lehrke, D.O.

Grade 3 GVHD, glandular apoptosis and crypt drop out, several apoptotic figures seen in field

Images hosted on other servers:

Various images

Flow cytometry description

Chronic graft versus host disease and the gastrointestinal tract

Differential diagnosis
Board review style question #1
What is the differential diagnosis for gastrointestinal GVHD?

  1. Chemotherapy
  2. CMV infection
  3. Cryptosporidiosis
  4. H. pylori infection
  5. Mycophenolate mofetil treatment
  6. NSAIDs
  7. Oral sodium phosphate bowel preparation
  8. All of the above
Board review style answer #1
H. All of the above

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Board review style question #2
What type of cell is generally resistant to GVHD in the GI tract and could be mistaken for an infiltrating adenocarcinoma in a single cell pattern in a biopsy specimen?

  1. Esophageal mucosa squamous cells
  2. Gastric endocrine cells
  3. Gastric glandular cells
  4. Goblet cells
  5. Paneth cells
  6. None of the above
  7. All of the above
Board review style answer #2
B. Gastric endocrine cells

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