A 54 year‐old woman with a history of Nissen Fundoplication presented with two weeks of worsening chronic epigastric pain and one day of fever. For two years, she had recurrent episodes of epigastric and right upper quadrant pain, characterized as sharp, “hunger pains,” occasionally radiating to her right scapula and associated with nausea. These episodes resolved spontaneously after one to five days and had no relation to meals. She denied vomiting, abnormal stools, weight loss, fatigue, or pulmonary symptoms. Esomeprazole provided no relief. A contrast‐enhanced CT of the abdomen two years prior revealed a 1.1cm right hepatic lobe hemangioma. Multiple endoscopies and abdomen ultrasounds were normal. Two weeks prior to presentation, she developed her typical epigastric pain that did not resolve, and the day prior to presentation had a temperature of 102°F. Physical exam revealed epigastric and right upper quadrant tenderness. Murphy’s sign was positive. Liver function tests and lipase level were normal. Ultrasound revealed multiple new subcentimeter hyperechoic foci in the right hepatic lobe and a normal gallbladder. A contrast‐enhanced CT of the abdomen revealed numerous small hepatic and splenic hypodensities, as well as nodules in both lung bases. A non‐contrast CT of the chest revealed numerous clustered, subcentimeter nodules in both lungs. Further work up included negative studies for HIV, quantiferon gold, Cryptococcus, Aspergillus, Histoplasma antigen, ANCA and anti‐nuclear antibodies. Transbronchial biopsy of the lung revealed non‐caseating granulomas, and a diagnosis of systemic sarcoidosis was made.
Our patient had an atypical presentation of sarcoidosis, a disease commonly encountered by internists. While liver involvement is not uncommon, abdominal symptoms are unusual, and only very rarely the presenting complaint. Our patient had intermittent abdominal pain for two years and no pulmonary symptoms. Nodules on contrast‐enhanced CT and MRI reveal hypodense/hypointense lesions, which can mimic an infectious, neoplastic or vasculitic process. Most patients will undergo extensive work‐up prior to making a tissue diagnosis, as was the case with our patient.
In patients with long‐standing abdominal pain and extensive negative workup, it may be useful to consider the diagnosis of sarcoidosis. Knowing the characteristic findings of disseminated nodular sarcoidosis on CT/MRI scan can potentially spare patients an invasive biopsy. Despite the dire radiographic appearance, prognosis is good, making prompt diagnosis essential in initiating appropriate treatment.
To cite this abstract:Tuohy C, Winer A, Park L, Odedosu T. Sarcoidosis Masquerading As Biliary Colic. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 655. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/sarcoidosis-masquerading-as-biliary-colic/. Accessed April 8, 2020.