Background :  Graft versus host disease( GVHD)  is rare but life threatening complication seen after intestinal transplanation.

Aim:  To report on our experience  of the children who developed GVHD after intestinal transplantation.

Methodology:    A retrospective study review of electronic database and medical records to identify GVHD in intestinal transplant children.

Results: The number of small bowel transplants was 88 (n= 80 children) .GVHD was seen in 9 (Male: Female 2:7) children (11%), all were blood group compatible transplants, apart from one child. The Type of transplant was  Isolated small bowel n= 3, Liver and bowel n= 3, Modified multivisceral  with a median age of n= 1.3.5 yrs (1.25-9.17).  Median time of onset of skin GVHD from the date of transplant was 4 months (1.5-7 months). Median duration of GVHD is 4 months (1 month- 1year). All of the 9 children had skin involvement. , 3 had gut involvement and 2 had liver involvement, 3 children had involvement of eyes. All of them were treated with high dose steroids and 3 children were responsive to steroids. In  6 other children with aggressive GVHD additional treatement was used ( steroid + IL2 blocker) n=1, steroid + IL2 blocker + infliximab n=3, steroid . In addition to the above treatment two children had mesenchymal stem cells and one child had extracorporeal photopheresis (ECP). Outcome: 2 died due to GVHD,   5 had complete resolution of GVHD (1 mesenchymal stem cells), 2 have ongoing chronic GVHD (1 MSC+ ECP). Donor cell chimerism studies showed increase in CD3+T cells with flare up if the rash and reduction in the CD3+T cells with improvement of the rash.

Conclusion: Skin GVHD can be fatal and if refractory to steroids and aggressive, then escalation t to  second line treatment with MSC and ECP  is necessary for successful recovery .