Gastrointestinal radiographic features of human graft-vs.-host disease

Following allogeneic bone marrow transplantation, graft-versus-host disease (GVHD) develops when the foreign donor lymphoid graft mounts an immunologic reaction against the skin, liver, and gastrointestinal tract of the host. The GVHD syndrome is characterized by skin rash, hepatocellular dysfunction, and secretory diarrhea with destruction of intestinal mucosa. The gastrointestinal radiographic manifestations of proven GVHD were studied in 16 allogeneic marrow recipients transplanted for aplasia (nine) or leukemia (seven). The radiographic findings revealed three distinct phases that correlated with the duration of active gastrointestinal GVHD: (1) Acute phase-seven examinations were performed 4-15 days after the onset of gastrointestinal GVHD, 19-44 days posttransplant. There were simultaneous and uniform changes in the stomach through the small bowel consisting of thickened or flattened mucosal folds, thickening of the bowel wall, rapid transit, and excess luminal fluid. (2) Subacute phase-17 examinations were performed 13-96 days after the onset of gastrointestinal GVHD (40-118 days posttransplant). Abnormalities similar to those of the acute phase were noted, often with a striking segmental distribution. (3) Resolution phase-three patients, who earlier had sequential examinations, were studied when GVHD was no longer clinically active, 43-46 days after the onset of gastrointestinal GVHD (52-94 days posttransplant). These examinations showed improvement, with no abnormalities or effacement of mucosal folds. Mural thickening was confined to the terminal ileum. Gastrointestinal GVHD resolved in the three survivors; it persisted until death in nine of 13. The pathogenic mechanisms and differential diagnosis of the radiographic abnormalities are discussed.