1882 Diagnosing Sarcoidosis From the Gastrointestinal Tract

Abstract

INTRODUCTION: Sarcoidosis is a multi-system disease with 90% occurrence in the lungs and mediastinal lymph nodes. Involvement of the gastrointestinal tract (GIT) occur in less than 1 % of cases. We illustrate a patient who presented with gastrointestinal symptoms leading to the diagnosis and multidisciplinary management of sarcoidosis. CASE DESCRIPTION/METHODS: 61-year-old African American female with gastroesophageal reflux disease and an umbilical hernia had constipation alternating with diarrhea and vomiting associated with greasy food. Examination showed an umbilical hernia and a soft, non tender abdomen. In her stool, pathogenic parasites and clostridium difficile was negative. Serum tissue transglutaminase and IgA levels were normal. Upper endoscopy and EUS revealed a polypoid mass in the gastric antrum which was limited to the mucosa. Histology showed inflammation, crypt abscesses and non caseating granulomas. Special stains for acid fast bacilli and fungi were negative. Quantiferon gold was negative. Colonoscopy was unremarkable. Suspicion for sarcoidosis led to a CT thorax, which revealed peri-hilar lymphadenopathy. The patient was sent to pulmonology and ophthalmology. Her symptoms were tackled without steroids in a symptomatic fashion. DISCUSSION: When sarcoidosis affects the GIT, the stomach is the most common site and with few reported cases in the esophagus, colon and rectum. Symptoms are non-specific, such as: nausea, vomiting, diarrhea, and abdominal pain. Diagnosis depends on three factors: biopsy confirming non-caseating granuloma in the GIT, involvement in at least one additional organ, and exclusion of other common granulomatous diseases, such as Crohn’s disease, tuberculosis and fungi. Our patient had an antral non-caseating granuloma.Multiorgan involvement was demonstrated by per-hilar lymphadenopathy. Tuberculosis and fungi were ruled out with negative stains and quantiferon gold. Nearly all patients with crohn’s disease develop distal colonic involvement, and upper GIT involvement is rare when there is no disease beyond the ligament of treitz. Our patient had multiple colonoscopies negative for Crohn’s. Management is based upon severity; asymptomatic patients require no treatment and severe cases receive glucocorticoids. Our patient’s did not need any steroids since subsequent endoscopies had no further granulomas. Although rare, sarcoidosis may involve the GIT, and clinicians should begin the work up if granulomas are found and refer the patient to the appropriate departments.