GASTRIC SARCOIDOSIS PRESENTING AS UPPER GI BLEEDING

Abstract

A 61-year-old woman with a history of sarcoidosis, currently in remission, presented with new-onset hematemesis, melena, and lightheadedness. She denied abdominal pain. She had been taking daily aspirin and naproxen for a recent injury. The patient was hemodynamically stable, and abdominal examination was benign. Hemoglobin was 7.6 g/dL. Upper endoscopy revealed multiple gastric ulcers with stigmata of recent bleeding; esophagus and duodenum were normal. Biopsies were taken, and a serology was sent for Helicobacter pylori. Her symptoms resolved after blood transfusion. She was discharged several days later with a hemoglobin of 10.6.g/dL. Discharge medications included pantoprazole 40 mg twice daily and her pre-admission dose of prednisone. The patient returned three days later with recurrent symptoms and three gram decrease in hemoglobin. Repeat upper endoscopy revealed two proximal antral non-bleeding ulcers. Serology from her prior admission was positive for Helicobacter pylori, and oral clarithromycin and amoxicillin were initiated. Biopsy results from her initial endoscopy became available that day and revealed noncaseating granulomas. She was placed on full-dose steroids forpresumed gastric sarcoidosis. Herremaining course was characterized by mild abdominal discomfort, but she had no further signs or symptoms of bleeding. She remained hemodynamically intact with stable hemoglobin. She was discharged several days later with plans for follow-up endoscopy in several weeks. Sarcoidosis is a systemic disease characterized by the presence of noncaseating granulomas, usually affecting intrathoracic structures. Clinically evident gastrointe stinal manifestations of sarcoidosis occur in less that 1% of patients known to have the disease. While sarcoidosis can be seen anywhere in the gastrointestinal tract, gastric disease is most common. Abnormalities seen may include ulceration or gastric lumenal narrowing. Histologic evidence of noncaseating granulomas with evidence of multisystem involvement establishes the disease. This case is unusual in that abdominal pain, apredominant and nearly universal feature seen with gastric sarcoidosis, was absent. Presentation with upper GI bleeding is an infrequent occurrence. Endoscopic findings, however, were consistent with those generally seen in patients with gastric manifestations of sarcoid. This case illustrates the importance of considering the diagnosis of gastric sarcoidosis in patients with pulmonary disease and gastric ulceration.