- Audience-Alienating Premise: Subverted. Despite the rather grotty, nauseous subject matter, Guts is just as well-received as Telgemeier's earlier works.
- On a subtler note, the back of the book shows a young, pre-Smile Raina sitting with, among others, Nicole. Who would go on to bully Raina for her teeth troubles in ''Smile''.
- Awesome Art: As usual, Braden Lamb's coloring is excellent and Telgemeier's character designs are attractive. Raina and Jane look closer to their age than in the few panels they shared together in Smile (where the art was less consistently good in the first third or so of the story) What really stands out in this book, however, are the use of green and black to represent Raina's stomach illness. Green, fuzzy colors on pitch black backgrounds do an amazing job capturing the feeling of solitary and unease these illnesses cause.
- Harsher in Hindsight: Michelle becomes a friend at the end of the book and promises to see Raina next year, but we never get a chance to see Michelle in Smile, implying she moved away, wasn't very close to Raina during that time, or (admittedly, rather likely) Raina just didn't think about Michelle while writing Smile. It becomes this trope if you subscribe to the first two theories, which basically means Raina lost both of her close friends right as her bullying started to ramp up.
- Heartwarming in Hindsight: Jane first appeared in Smile, nine years before Guts came out, for only a page or so, as the only one of Raina's circle of friends who was consistently nice to her. We get to see Raina and Jane as the best of friends here, which makes the brief dialogue between Raina and her mother in Smile about how much Raina misses her friend all the more impactful.
- The scenes with Nicole also qualify: they show that Nicole wasn't always the bully she was in Smile and became so more out of ignorance and immaturity than malice.
- Jerkass Woobie: Michelle; she teases Raina and Jane and is implied to be a bit of a bully. But it's clear that she's an immature kid who lacks social skills, and even before befriending Jane she shows a more vulnerable side when she looks genuinely hurt when Raina insults her family's favorite food (waldorf salad) in front of the entire class. Eventually, she has to get surgery done, and Raina - who has finally come to grips with the fact that Jane and Michelle are friends - leads the class in an effort to make her a giant card. Michelle absolutely adores it.
- The Woobie: While Raina is neither wholly pure or evil in any of the books, here she lacks the more jerkish moments she has in Smile and Sisters.
- Nightmare Fuel: Poor Raina's panic attacks. It feels all too real, that sense of uncontrollable fear.
- Tear Jerker: Nicole revealing her father is an alcoholic who often yells at her and her brother. It paints a poignant picture that offers a possibility on why she came to bully Raina in ''Smile''.
- Raina learning that Jane has befriended Michelle. It's sobering for her to see her friend (allegedly) grow distant as she so happily bonds more and more with her bully. She even calls it a Gut Punch.
YMMV / Guts Raina Telgemeier