SARCOIDOSIS INVOLVING THE LIVER AND STOMACH

M Nazareth MD, TA Shaw-Stiffel MDCM

Rochester General Hospital and Strong Memorial Hospital, University of Rochester, Rochester, New York, and Center for Liver Diseases, UPMC Presbyterian Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania, USA

INTRODUCTION: Sarcoidosis is a relatively common, chronic, multi-systemic disease of unknown etiology characterized by non-caseating epithelioid granulomas mostly affecting the lung and lymph nodes. We present an unusual case of sarcoidosis in both the liver and the stomach.
CASE: A 68 yo African-American man presented with 25lb weight loss, anorexia, and abnormal liver tests (Alk Phos 942, AST 129, ALT 73, Total Bili 2.7). Routine viral and other serologic tests were negative. Imaging studies revealed multiple liver lesions and extensive lymph-adenopathy. A liver biopsy showed several non-caseating granulomas, cholangiolar proliferation and portal inflammation, all consistent with hepatic sarcoidosis. Stains for AFB and other pathogens were negative. Serum ACE level was elevated at 217 IU/L. Chest X-ray was normal. The patient was treated with Prednisone for 2 months during which his symptoms resolved and his liver tests improved significantly. One year later, he again developed weight loss, anorexia and new onset of iron deficiency anemia. Colonoscopy showed only a small tubular adenoma but upper endoscopy revealed multiple small nodules throughout the stomach mostly confined to the antrum. Biopsies showed non-caseating granulomas. Stains were negative for pathogens including H. pylori. The patient was resumed on Prednisone with symptom resolution.
DISCUSSION: Gastrointestinal involvement with sarcoidosis is rare but when it does occur, the stomach is the most common site. Our case is one of only a handful reported in the literature to have biopsy-proven involvement of both the liver and the stomach. Other causes such as TB, MAC and Whipple's disease were excluded.
CONCLUSION: Our case exhibits a rare form of sarcoidosis affecting both the liver and the stomach. Prednisone led to improvement in the patient's symptoms in the short-term. Whether or not steroids influence long-term outcome in these cases has yet to be determined.