Abstract： Objective To summarize the timing and diagnostic value of endoscopic biopsy of intestinal graft after small bowel transplantation (SBTx).Methods Fifteen cases of SBTx were divided into 3 eras:era Ⅰ (1994-1995)-3 cases of SBTx treated with cyclosporine-based immunosuppression; era Ⅱ (2003-2006)-7 cases of SBTx treated with tacrolimus-based immunosuppression,and era Ⅲ (2007-present) than CVC group 5 cases of SBTx treated with Atemtuzumab induction therapy and maintenance tacrolimus monotherapy.The scheme of endoscopic surveillance was initially used in era Ⅲ, the first endoscopic biopsy was performed on postoperative day 3,2 times weekly during the first month, followed once weekly during months 2-3, once every other week during months 4-6 and once monthly thereafter.When clinical signs and symptoms of rejection were present, and during rejection episodes, the additional endoscopic biopsies were also performed.Results A total of 276 biopsies of these 15 SBTx recipients were obtained.Fifty-one biopsies (18.5%) were diagnosed as acute cellular rejection (ACR), which included IND to mild (n = 32,11.6 %), moderate (n = 9,3.3 %), and severe (n = 1 0, 3.6 %), two biopsies (0.7 %) were diagnosed as cytomegalovirus (CMV) enteritis and other 2 biopsies (0.7 %) bacteria enteritis.The ACR episodes verified by biopsy pathology and undergoing anti-rejection treatment were 20 (11 IND to mild,5 moderate,and 4 severe) ,and 1 episode of CMV enteritis and 1 episode of bacteria enteritis were observed.Conclusion Endoscopic surveillance and biopsy pathology is crucial diagnostic tool for ACR and sepsis.ACR surveillance after SBTx and early diagnosis of ACR could be made with scheming endoscopic biopsies.Endoscopic biopsy can be used to make differential diagnosis when clinical signs and symptoms were present, and to guide the treatment during anti-rejection episode.