An uncommon cause of chronic diarrhea

Abstract

Clinical presentation: A 48 year old African American female was referred to our GI clinic after undergoing an exhaustive series of tests for the work up of chronic diarrhea, upper abdominal pain and microcytic anemia for 2 years. Workup performed by her physicians included negative stool studies, normal ultrasound and MRI of abdomen, upper endoscopy (EGD) that revealed nonerosive gastritis, and a colonoscopy that revealed diverticulosis. She was then referred to our GI clinic for her chronic symptoms and recent abnormal liver enzymes. Her past medical history was significant only for dysmenorrhea. She was not on any medications. She was neither an alcoholic nor a tobacco user. She denied any pertinent family history, nausea, vomiting, hematochezia, or melena. She did report an involuntary weight loss. The physical exam was benign except for a palpable, nontender liver and mild epigastric tenderness. No lymphadenopathy or stigmata of chronic liver disease were appreciated. Laboratory findings included mild microcytic anemia, elevated transaminases (ALT/AST=55/63 iu/l), alkaline phosphatase (501 iu/l) and GGT (495 iu/l). Further laboratory testing revealed a negative HIV test, negative Hepatitis serology, negative autoimmune markers and negative IBD serology panel. However, ACE level (104 iu/l) and ESR (64 mm) were elevated. Chest X-Ray revealed bilateral hilar lymphadenopathy. A repeat colonoscopy was unremarkable and random biopsies were non-diagnostic. A repeat EGD revealed mild gastritis. Biopsies of the gastric mucosa revealed multiple non-caseating granulomas and marked acute and chronic pititis. It also revealed H. pylori organisms. AFB and GMS stains were negative for acid fast and fungal organisms, respectively. In the presence of high ACE levels, cholestatic liver enzyme pattern, gastric noncaseating granulomas and hilar lymphadenopathy, a diagnosis of gastric sarcoidosis was made.