Endoscopic Ultrasound: Role in Diagnosis of Hepatic Sarcoidosis

Abstract

A 46-year-old female presented with shortness of breath, dry cough, and diffuse abdominal pain for one week. She denied issues with weight loss, pruritus, rectal bleeding, or hematemesis. Family history was notable for asthma; there was no family history of lung cancer or sarcoidosis. Physical exam was unremarkable with no cutaneous findings. Significant laboratory values included: aspartate aminotransferase (AST) 48, alanine aminotransferase (ALT) 64, alkaline phosphatase 375, erythrocyte sedimentation rate (ESR) 35, angiotensin-converting enzyme (ACE) 116. Tuberculosis testing, anti-mitochondrial and anti-smooth muscle antibody markers were negative. Due to her unknown etiology of abdominal pain, computed tomography (CT) abdomen and pelvis with contrast was performed showing mild dilatation of the pancreatic duct and a suggestion of a mass in the head of the pancreas (Fig. 1). Magnetic resonance imaging (MRI) of the abdomen confirmed abnormal-appearing confluent soft tissue within the porta hepatis and liver hilum, encircling the patient's main portal vein and extending into the periceliac and gastrohepatic regions. It appeared separate and of different signal intensity than adjacent pancreas and liver. An endoscopic ultrasound (EUS) was performed noting the mass (Fig. 2). Fine needle aspiration (FNA) followed with subsequent analysis. Cytology noted findings consistent with sarcoidosis. CT chest confirmed pulmonary involvement, including mediastinal and hilar lymphadenopathy.Figure 1Figure 2Roughly 50-65% of patients with sarcoidosis have hepatic granulomas on biopsy but only 5-15% of the patients present with symptoms. Unlike traditional cytologic diagnosis of hepatic sarcoidosis via invasive liver biopsy, our patient had an EUS-FNA of a suspicious mass located in the hilum of the liver. Traditionally, bronchoscopy with transbronchial lung biopsy is performed in suspected sarcoidosis patients. If unsuccessful, mediastinoscopy is often performed as the next diagnostic procedure. EUS-FNA provides a nonsurgical alternative by aspirating mediastinal lymph nodes from the esophagus. Our case is unique in that EUS-FNA did not sample mediastinal lymph nodes, but instead sampled the actual mass in the hilum of the liver. Hepatic granulomas may be due to other underlying causes, such as tuberculosis, primary biliary sclerosis, or drug-induced disease. Thus, in suspected cases of hepatic sarcoidosis, liver biopsy is recommended for moderate-severe liver function abnormalities to rule out other causes. EUS-FNA has superior predictive value and lower complication risk than traditional liver biopsy and should be considered as a modality for diagnosis of hepatic sarcoidosis.