2656 A Rare Case of Gastrointestinal and Hepatic Extra-Pulmonary Involvement of Sarcoidosis Mimicking Crohn’s Disease

Abstract

INTRODUCTION: Sarcoidosis is a systemic disease characterized by noncaseating granulomas. While pulmonary and lymphatic involvement is common, gastrointestinal involvement is rare. We report a case of diffuse gastrointestinal and hepatic involvement of sarcoidosis initially mimicking Crohn’s disease. CASE DESCRIPTION/METHODS: A 62 year-old man with history of chronic thrombocytopenia and sarcoidosis, presented for further evaluation of suspected Crohn’s disease after undergoing high-risk surveillance colonoscopy. The colonoscopy was significant for congested mucosa in the terminal ileum and colon as well as multiple colonic erosions (Figure 1). Pathology showed chronic active colitis with crypt abscesses in the left colon and poorly formed granulomas without dysplasia in the right colon suggestive of Crohn’s disease. The patient reported no gastrointestinal or systemic complaints and stated good control of his underlying sarcoidosis. An esophagogastroduodenoscopy (EGD) was then completed and showed moderately-congested mucosa with many non-bleeding gastric body, antral and superficial duodenal ulcers positive for Helicobacter pylori. Despite normal liver chemistries, given the presence of indirect signs of portal hypertension (splenomegaly, thrombocytopenia), a transjugular liver biopsy was pursued which was significant for portal hypertension as well as moderate chronic portal hepatitis with cirrhosis, non-necrotizing granulomas consistent with sarcoid involvement, and no histologic features of PBC (Figure 2). Labs, including hepatitis B and C serologies, ANA, and anti-mitochondrial antibody, were grossly unremarkable. After establishing an elevated portal pressure gradient, a repeat EGD was done approximately six-months later which was significant for grade I esophageal varices, erythematous and nodular mucosa in the gastric antrum and erythematous duodenopathy; biopsies were negative for H. Pylori. The patient was then referred back to pulmonology for further assessment of his pulmonary disease prior to consideration of treatments for his progressed liver disease. DISCUSSION: Typically presenting with pulmonary involvement, gastrointestinal involvement of sarcoidosis, particularly of the small bowel, is a very rare extra-pulmonary manifestation of sarcoidosis. Hepatic involvement with progression to cirrhosis is uncommon. Above, we present a very interesting case with both diffuse gastrointestinal and hepatic sarcoidosis subsequently noted to have progressive liver disease with portal hypertension.