Clinical Features and Outcomes in Patients with Inflammatory Bowel Disease and Concomitant Sarcoidosis

Abstract

Purpose: Some clinical features of sarcoidosis and inflammatory bowel disease (IBD) are similar, such as the presence of non-caseating granulomas, and these conditions were recently shown to share a genetic basis. We sought to describe the clinical features and outcomes of patients with IBD and sarcoidosis. Methods: We utilized a central diagnostic index to identify potential cases with IBD and sarcoidosis seen at our institution between 1995 and 2012. These were identified using ICD-9 codes, and diagnoses were confirmed by manual chart review. Clinical features of both conditions were recorded, as well as medical and surgical therapies and outcomes. Results: Forty-five patients were identified. Median age at IBD diagnosis was 41.6 years (range, 9.5-73.8). Fifty-six percent were males. Crohn's disease occurred in 21 (47%; six ileitis, four colitis, nine ileocolitis, one gastroduodenal, one pan-intestinal), and ulcerative colitis occurred in 24 (53.3%; three proctitis, five left-sided, 13 pancolitis, three unknown). Median age at sarcoidosis diagnosis was 44.4 years (range, 12.5-69.6). Sarcoidosis preceded IBD diagnosis in 23 (51.1%), and IBD preceded sarcoidosis diagnosis in 20 (44.4%). Predominant sites of sarcoid involvement were pulmonary in 35 (77.8%), lymph nodes in six (13.3%), central nervous system in four (8.9%), skin in three (6.7%), and conjunctiva in three (6.7%). Sarcoidosis diagnosis was predominantly made by biopsy in 25 (55.6%), imaging in 16 (35.6%), and mediastinoscopy/bronchoscopy in 12 (26.7%). Median follow-up after first visit was 6.2 years (range, 0-39.9). Initial medications for IBD after first visit included 5-ASA in 25 (55.6%), steroids in 14 (31.1%), azathioprine in five (11.1%), omeprazole in one (2.2%), and antibiotics in one (2.2%). Subsequent medications included 5-ASA in 21 (46.7%), steroids in 18 (40%), azathioprine in 13 (28.9%), anti-TNF in 10 (22.2%), no medications in 14 (31.1%), methotrexate in two (4.4%), and antibiotics in two (4.4%). Twelve patients (26.7%) required surgery for IBD. Hospitalizations occurred in 27 (60%). Medications for sarcoidosis included prednisone in 18 (40%), methotrexate in three (6.7%), and none in eight (17.8%). Pulmonary function tests at sarcoidosis diagnosis showed median FEV1 of 2.6 L (80% predicted), and median DLCO was 82% predicted. In follow-up, these improved to 2.69 L (85% predicted) and 86% predicted, respectively. Radiographic pulmonary improvement was noted in 65% of the 23 patients with serial lung films. Conclusion: Sarcoidosis is occasionally seen in conjunction with both major IBD subtypes. Treatment of the underlying IBD frequently is associated with clinical improvement in sarcoidosis. The presence of sarcoidosis is not a contraindication to aggressive medical therapy of IBD.