ISSN: 2373-6372GHOA

Gastroenterology & Hepatology: Open Access
Volume 4 Issue 4 - 2016
Multiple Facets of Abdominal Sarcoidosis
Claudio Tana1*, Marco Tana2, Silvio di Carlo3 and Mauro Silingardi1
1Internal Medicine Unit, Guastalla Hospital, Italy
2Internal Medicine Unit, AUSL 5 Spezzino, Italy
3Geriatrics Unit, AUSL Pescara, Italy
Received: January 08, 2016 | Published: March 28, 2016
*Corresponding author: Claudio Tana, Internal Medicine Unit, Guastalla Hospital - AUSL Reggio Emilia, Via Donatori di Sangue 1, 42016 Guastalla (RE), Italy, Tel: +39 0522 837354; Fax: +39 0522 837284; Email:
Citation: Tana C, Tana M, Carlo SD, Silingardi M (2016) Multiple Facets of Abdominal Sarcoidosis. Gastroenterol Hepatol Open Access 4(4): 00105. DOI: 10.15406/ghoa.2016.04.00105


Sarcoidosis; Liver; Spleen; Ultrasound; Computed tomography; Magnetic resonance imaging


US: Ultrasound; CECT: Contrast Enhancement Computed Tomography; MRI: Magnetic Resonance Imaging; CEUS: Contrast Enhanced Ultrasound


The complexity of sarcoidosis is in part due to its multiple clinical manifestations that not only involve organs such as lungs but also sites such as liver and spleen. Abdominal manifestations of sarcoidosis are common if paucy- or asymptomatic forms of the disease are considered, with a reported frequency of 50-70% [1]. Virtually every organ can be involved by sarcoid lesions, but liver and spleen are the sites most often affected. Rarely pancreas, gastrointestinal and urinary system have been described as organs involved from sarcoidosis [2-5]. Increase of liver enzymes (e.g., transaminases, gamma-gt and alkaline phosphatases) is commonly observed in patients with sarcoidosis [6], but should not considered a priori evidence of hepatic involvement in patients affected by pulmonary form of sarcoidosis unless confirmed by biopsy or, at least, by imaging. Other concomitant etiologies can indeed occur such as non-alcoholic fatty liver disease and viral hepatitis and differential diagnosis can be challenging if a high clinical suspect does not occur in these situations [7,8].

Besides asymptomatic form, sarcoidosis of the liver can manifest clinically with a wide range of symptoms, such as anorexia, weight loss, night sweats and fever. Symptoms derived from intrahepatic cholestasis (e.g., jaundice and pruritus), liver failure or those derived from portal hypertension (e.g., ascites, bleeding from gastroesophageal varices rupture) due to granulomas involving the portal triad can be rarely observed. Sometimes, peritoneum can be infiltrated by multiple nodules mimicking peritoneal carcinomatosis [9].

If clinically suspected, abdominal involvment by sarcoidosis can be first detected by imaging studies. Conventional ultrasound (US), followed by second imaging techniques such as contrast enhancement computed tomography (CECT) or magnetic resonance imaging (MRI) shows homogenous hepatomegaly, fatty liver disease-like pattern with increase echogenicity, parenchymal inhomogeneity with coarsening pattern or multiple prominent nodules. Rarely, isolated hepatic nodules can be found. Such masses should be differentiated with focal malignant lesions. Other common findings are splenomegaly, with or without prominent nodules and lymph node enlargement [7,9-11]. Overcoming common limits of traditional contrast-imaging techniques, contrast-enhanced ultrasound (CEUS), a novel safe US technique, has documented reliability to detect nodules in some case series, where conventional US was usually negative [8,12,13].

Histopathologically, granulomas are characteristically non-caseating and characterized by accumulation of histiocytes, lymphocytes, sparse lymphoid and a variable amount of fibrosis and collagen. The term granuloma derives from the Latin granum (grain) and means the typical gross appearance of these lesions [14]. These lesions seem to represent a continuous inflammation process due to incomplete antigen degradation associated with chronic activity of cell mediated immunity [15]. The most important problem of abdominal sarcoidosis, but also of systemic disease, is the wide range of disorders that comes into differential diagnosis. Sarcoidosis can manifest with similar clinical and radiological findings of conditions such as tuberculosis, lymphoma, and neoplastic disorders. It should not surprise therefore that definitive diagnosis is very difficult to obtain in some occasions, and these considerations are even more true if both conditions (e.g., sarcoidosis and malignant conditions) are associated in the same patient. Several studies have demonstrated that sarcoidosis can be a risk factor for malignant degeneration, where continuous inflammatory process represents the leading mechanism [15-17]. A correct diagnosis is therefore essential and biopsy is necessary to demonstrate non-caseating granulomas. Sites for biopsy can be liver and visceral lymph nodes if more accessible sites (e.g., skin, superficial lymph nodes) are not available. Spleen has been considered in the past as an additional site of biopsy [18] but can increase the risk of serious complications (e.g., bleeding, GI perforation). In conclusion, a definitive diagnosis of abdominal sarcoidosis should be globally based on a thorough clinical algorithm with evaluation of the patient, laboratory tests, biopsy from accessible site that demonstrates characteristic granulomatous lesions and on the exclusion of infectious and/or non-infectious immunogenic factors from the epithelioid cell granulomas [19-22].


  1. Gezer NS, BaÅŸara I, Altay C, Harman M, Rocher L, et al. (2015) Abdominal sarcoidosis: cross-sectional imaging findings. Diagn Interv Radiol 21(2): 111-117.
  2. Yao Y, Jiang F, Jin Z (2016) Pancreatic sarcoidosis in association with type 1 autoimmune pancreatitis: a case report and literature review. Pancreas 45(1): e7-e8.
  3. Matsubara T, Hirahara N, Hyakudomi R, Fujii Y, Kaji S, et al. (2015) Early gastric cancer associated with gastric sarcoidosis. Int Surg 100(5): 949-953.
  4. Erra P, Crusco S, Nugnes L, Pollio AM, Di Pilla G, et al. (2015) Colonic sarcoidosis: unusual onset of a systemic disease. World J Gastroenterol 21(11): 3380-3387.
  5. Famularo G, Nicotra GC, Minisola G, De Simone C (2006) Sarcoid relapse with isolated kidney involvement. Intern Emerg Med 1(2): 170-172.
  6. Cremers J, Drent M, Driessen A, Nieman F, Wijnen P, et al. (2012) Liver-test abnormalities in sarcoidosis. Eur J Gastroenterol Hepatol 24(1): 17-24.
  7. Warshauer DM, Lee JKT (2004) Imaging manifestations of abdominal sarcoidosis. AJR Am J Roentgenol 182(1): 15-28.
  8. Tana C, Dietrich CF, Schiavone C (2014) Hepatosplenic sarcoidosis: contrast-enhanced ultrasound findings and implications for clinical practice. Biomed Res Int 2014: 926203.
  9. Ebert EC, Kierson M, Hagspiel KD (2008) Gastrointestinal and hepatic manifestations of sarcoidosis. Am J Gastroenterol 103(12): 3184-3192.
  10. Warshauer DM, Molina PL, Hamman SM, Koehler RE, Paulson EK, et al. (1995) Nodular sarcoidosis of the liver and spleen: analysis of 32 cases. Radiology 195(3): 757-762.
  11. Hoeffel C, Bokemeyer C, Hoeffel JC, Gaucher H, Galansky M, et al. (1996) CT hepatic and splenic appearances with sarcoidosis. Eur J Radiol 23(2): 94-96.
  12. Tana C, Iannetti G, D Alessandro P, Tana M, Mezzetti A, et al. (2013) Pittfalls of contrast-enhanced ultrasound (CEUS) in the diagnosis of splenic sarcoidosis. J Ultrasound 16(2): 75-80.
  13. Tana C, Iannetti G, Mezzetti A, Schiavone C (2014) Splenic sarcoidosis remains a diagnostic challenge. J Clin Ultrasound 42(3): 156.
  14. Tana C, Wegener S, Borys E, Pambuccian S, Tchernev G, et al. (2015) Challenges in the diagnosis and treatment of neurosarcoidosis. Ann Med 47(7): 576-91.
  15. Tana C, Giamberardino MA, Di Gioacchino M, Mezzetti A, Schiavone C (2013) Immunopathogenesis of sarcoidosis and risk of malignancy: a lost truth? Int J Immunopathol Pharmacol 26(2): 305-313.
  16. Hammen I, Sherson DL, Davidsen JR (2015) Systemic sarcoidosis mimicking malignant metastatic disease. Eur Clin Respir J 2: 26761.
  17. Chopra A, Judson MA (2015) How are cancer and connective tissue diseases related to sarcoidosis? Curr Opin Pulm Med 21(5): 517-524.
  18. Keogan MT, Freed KS, Paulson EK, Nelson RC, Dodd LG (1999) Imaging-guided percutaneous biopsy of focal splenic lesions: update on safety and effectiveness. AJR Am J Roentgenol 172(4): 933-937.
  19. Joint Statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS), the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee (1999) Statement on sarcoidosis. J Am J Respir Crit Care Med 160(2): 736-755.
  20. Chokoeva AA, Tchernev G, Tana M, Tana C (2014) Exclusion criteria for sarcoidosis: a novel approach for an ancient disease? Eur J Int Med 25(10): e120.
  21. Valeyre D, Prasse A, Nunes H, Uzunhan Y, Brillet PY, et al. (2014) Sarcoidosis. Lancet 383(9923): 1155-1167.
  22. Tchernev G, Chokoeva AA, Tana C, Patterson JW, Wollina U, et al. (2015) Sarcoid sine sarcoidosis? A classificative, semantic and therapeutic dilemma. J Biol Regul Homeost Agents 29(1 Suppl): 33-34.
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