Sarcoidosis bowel symptoms

Sarcoidosis bowel symptoms DEFAULT

Gastric sarcoidosis mimicking irritable bowel syndrome-Cause not association?

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Sarcoidosis is an immune-mediated condition affecting multiple organs, especially the lungs, lymph nodes, skin and eyes.1,2 Gastrointestinal involvement is considered to be a rare complication of sarcoidosis, occurring in <10% of the patients during the course of the disease.3,4 We recently observed the interesting case of a patient who developed duodenal involvement as the first manifestation of sarcoidosis.

A 36-year-old woman, with unremarkable previous medical history, presented with a 4-month history of asthenia and a 10-kg weight loss; she also complained of abdominal pain, diarrhea and arthralgia. At admission, physical examination demonstrated abdominal pain to palpation, involving the epigastric area; general physical examination was otherwise normal. Laboratory findings disclosed the following: erythrocyte sedimentation rate 66 mm/h; C-reactive protein 25 mg/l; hemoglobin 12 g/dl; white blood cell count 9.1 × 109/l; and platelet count 450 × 109/l. Other routine biochemical tests, including renal and liver tests, vitamin B12 and folic acid blood levels, as well as blood and urinary protein immunoelectrophoresis, were normal. Stool cultures (Yersinia, Salmonella, Camplylobacter and Shigella) yielded negative results. Because of abdominal clinical manifestations, gastroscopy was performed, which showed granulomatous duodenal involvement (Figure 1). Histological examination of duodenal lesion specimens showed numerous non-caseating epithelioid granulomas; there was no evidence of Helicobacter pylori. Special stains and cultures of the duodenum biopsy specimens were negative for Mycobacterium species and fungi; polymerase chain reaction amplification of Mycobacterium tuberculosis complex and bacterial 16S ribosomal RNA further proved negative. Tuberculin skin test was negative; further microbiological studies (Ziehl–Neelsen stain and cultures) in sputum and urine products were also negative for acid-fast bacilli. Thoracic and abdominal computed tomography-scan showed bilateral hilar lymphadenopathy. Pulmonary function tests revealed a mild decrease of diffusing capacity for carbon monoxide (68%) without restrictive pattern. Bronchoscopy was systematically performed; histological examination also showed numerous non-caseating epithelioid granulomas. Bacterial (Treponema pallidum) and viral (cytomegalovirus, Epstein–Barr virus, Herpes simplex virus, hepatitis B and C, human immunodeficiency virus) were negative. Autoantibody screening also yielded negative results for rheumatoid factors, anti-nuclear and anti-neutrophil cytoplasmic antibodies, anti-Saccharomyces cerevisae antibodies, anti-endomysium and anti-transglutaminase antibodies; serum angiotensin-converting enzyme level was elevated: 97 IU/l (n < 68). Other investigations, including accessory salivary gland histological examination, colonoscopy and small bowel barium meal were normal. A definite diagnosis of small intestinal involvement related to sarcoidosis was made. Because of the systemic manifestations related to sarcoidosis, steroid therapy, at an initial dose of 30 mg daily was initiated. The patient's condition improved rapidly with regression of clinical symptoms and weight gain.

Gastrointestinal involvement is rare in sarcoidosis. Previous autopsy series have, in fact, found no gastrointestinal impairment in patients with sarcoidosis,5 while other authors have observed subclinical gastrointestinal sarcoidosis in 5–10% of the patients.2,3 The stomach, particularly the antrum, is the most frequent extra-hepatic organ to be involved; on the other hand, the small intestine is the least common.2,3 Intestinal involvement usually occurs in patients with chronic multisystem sarcoidosis, although it may be the first manifestation of the disease;2,3 in our patient, small bowel impairment revealed sarcoidosis. Clinical manifestations of sarcoidosis-related intestinal impairment are non-specific, including epigastric and peri-umbilical pain, diarrhea, weight loss, malabsorption, protein-losing enteropathy or duodenal obstruction.2,3,6,7 Nevertheless, the definite diagnosis of sarcoidosis-related small intestinal impairment can only be established after exclusion of other conditions.8 In our patient, a diagnosis of sarcoidosis-related small intestinal involvement could be made as: (i) the extensive search for other conditions was unsuccessful, including infections (tuberculosis, Whipple's disease and syphilis), Crohn's disease, celiac disease, foreign body reaction, autoimmune diseases, as well as drug-related lesions and malignancy (lymphoma, carcinoma); (ii) there was a combination of the histological granulomatous duodenal involvement and the pulmonary lesions; and (iii) the resolution of clinical manifestations took place after initiation of steroid therapy. Our findings underline that when unexplained intestinal manifestations are noted, careful clinical examination should systematically be performed in order to detect underlying sarcoidosis. Moreover, our data also indicate that patients with sarcoidosis who exhibit persistent diarrhea and abdominal pain should be investigated for intestinal sarcoidosis. Therapy of sarcoidosis-related small intestinal involvement remains controversial. Previous authors have suggested that steroids should be considered in the group of the patients who exhibit: (i) symptomatic intestinal lesions and (ii) intestinal involvement associated with multivisceral and severe sarcoidosis. The recommended starting dose of steroid therapy is 20–40 mg daily, with gradual dose decrease subsequently.9,10 Steroid therapy has been reported to improve intestinal gastrointestinal symptoms in 66% of the patients. 9,10

Finally, our case report reinforces the possibility of an unusual presentation of sarcoidosis. Indeed, physicians should be aware that small bowel involvement may be related to sarcoidosis, resulting in earlier diagnosis and management. In such patients exhibiting unusual intestinal manifestations, diagnosis of sarcoidosis relies on compatible clinical signs, evidence of non-caseating granulomas and exclusion of underlying conditions, especially infections and other granulomatous diseases. Moreover, because small intestinal involvement may precede other signs of sarcoidosis, our findings indicate that when unexplained intestinal involvement is noted, an evaluation for sarcoidosis should be made.


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Sinonasal involvement in sarcoidosis. A case-control study of 20 patients



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A study of sarcoidosis based on a combined investigation of 160 cases including 30 autopsies from the Johns Hopkins Hospital and Massacussetts General Hospital



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Multiple antral ulcers in gastric sarcoid

J Clin Gastroenterol


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Sarcoidosis Could Be Cause of Digestive Tract Ailments Especially in Afro-Caribbeans, Study Suggests

Weight loss and digestive symptoms such as nausea, vomiting, diarrhea, and digestive bleeding could be linked to digestive tract sarcoidosis (DTS), especially in patients of African and Afro-Caribbean origin, according to a study conducted by researchers in France. DTS should therefore be considered in the presence of these symptoms, and in every patient with digestive granulomatosis.

The team analyzed 25 patients with DTS (more than 50 percent of whom were of African or Afro-Caribbean origin), and compared the characteristics of the disease with 50 patients with non-digestive tract sarcoidosis, and 100 controls with Crohn’s disease (an inflammatory bowel disease).

Researchers found that people with DTS had no swollen lymph nodes in their chest, but instead had lesions mainly in the stomach and also in the colon, rectum, and, to a lesser extent, in the esophagus and in the duodenum (the first section of the small intestine).

Even though sarcoidosis mainly affects lungs and chest lymph nodes, in very rare cases (01 percent to 1.6 percent) it can also involve the digestive tract. Because the presence of granulomas in the digestive system is mainly associated with Crohn’s disease, the researchers compared DTS with Crohn’s disease to determine the characteristics that could differentiate these two conditions.

The team found that DTS more often involved the upper digestive tract, especially the stomach, while patients with Crohn’s disease more often had lesions in the ileum (the final section of the small intestine), and the colon. In addition, patients with DTS often had other complications, such as interstitial lung disease, swollen lymph nodes, granulomatous hepatitis, high calcium levels in the blood, and central nervous system or heart involvement, which are not typically seen in Crohn’s disease.

Interestingly, DTS was more frequently observed in African or Afro-Caribbean patients compared to Crohn’s disease.

“The absence of ileal or colonic involvement in a patient with a granulomatous digestive tract disease, especially with an African or Afro-Caribbean origin, must encourage considering the diagnosis of sarcoidosis,” the research team wrote in their report.

In the last follow-up assessment performed, 76 percent of the patients with DTS recovered by themselves (clinical digestive remission) and did not need surgery, while a third of the patients with Crohn’s disease did require a surgical intervention.

“The differential diagnosis with Crohn’s disease could be an issue with DTS. Nevertheless, the two diseases often have different clinical presentation and outcome,” the research team concluded.

The study, “Digestive-tract sarcoidosis: French nationwide case–control study of 25 cases,” was published in the journal Medicine.

Sarcoidosis, Causes, Signs and Symptoms, Diagnosis and Treatment.

Digestive-tract sarcoidosis

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