Nausea, Vomiting, and Weight Loss: Common Symptoms of an Uncommon Disease

Abstract

Question: A 36-year-old black woman with no significant past medical history presented with progressive nausea, vomiting, and weight loss for several months. She had no lymphadenopathy or hepatomegaly on physical examination. Laboratory tests showed hemoglobin of 11 g/dL and normal liver functions tests. An esophagogastroduodenoscopy revealed diffuse erythematous, nodular, friable mucosa in the stomach and the antrum was not easily distended on insufflations (Figure A). The pylorus was narrowed but was easily traversed by the endoscope (Figure B). Computed tomography of the abdomen and pelvis showed thickening of the antral wall of the stomach but was otherwise unremarkable (Figure C, arrow). An upper gastrointestinal series confirmed a conical configuration and lack of distension throughout the gastric antrum with patulous pyloric channel (Figure D). Small bowel follow-through showed no evidence of active or chronic inflammatory disease in the small intestine. What is your diagnosis? Look on page 574 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Pathology findings from the gastric biopsy demonstrated chronic severely active gastritis with noncaseating granuloma formation (Figure E). Additional stains for Helicobacter pylori, acid-fast bacilli, and Grocott's methenamine silver were negative. Further workup showed CRP <3 mg/L, antinuclear antibody <40 titer, antineutrophil cytoplasmic antibody nonelevation, rapid plasma reagin nonreactive and, Quantiferon Tb-gold test negative. Tuberculosis was unlikely. Clinicopathologic findings were consistent with gastric sarcoidosis. Chest and abdominopelvic computed tomography showed no evidence of adenopathy or other organ involvements. Patient responded to oral prednisone and had subsequent resolution of symptoms. She successfully tapered off prednisone over the several weeks. Although the stomach is the most commonly involved organ in the gastrointestinal sarcoidosis, isolated gastric sarcoidosis occurs in <1% of patients with sarcoidosis.1Afshar K. BoydKing A. Sharma O.P. Shigemitsu H. Gastric sarcoidosis and review of the literature.J Natl Med Assoc. 2010; 102: 419-422Crossref PubMed Scopus (28) Google Scholar Clinical manifestations are usually related to the anatomical alterations caused by disease involvement. The common imaging findings are mucosal nodularity, thickened irregular folds and deformity of the antrum.2Warshauer D.M. Lee J.K. Imaging Manifestations of Abdominal Sarcoidosis.AJR Am J Roentgenol. 2004; 182: 15-28Crossref PubMed Scopus (137) Google Scholar Diagnosis is based on histologic evidence of noncaseating granuloma in the context of clinically relevant features. Other diseases that may yield similar pathology, including Crohn’s disease, tuberculosis, Whipple’s disease, and fungal or parasite infections, should be ruled out. Glucocorticoid is the treatment of choice. Disease activity should be monitored clinically and immunosuppressants should gradually be tapered while monitoring clinical course. The role of serum ACE level for disease monitoring is limited. Surveillance endoscopy is indicated if disease recurrence is clinically suspected. This case highlights that gastric sarcoidosis should be considered when there is mucosal change suspicious of infiltrative process in gastrointestinal tract.