Treatment of a Gastrointestinal Sarcoidosis Flare: A Multidisciplinary Approach for a Multisystem Disease

Abstract

Patient: Female, 68-year-old Final Diagnosis: Sarcoidosis Symptoms: Dysphagia • epigastric pain • nausea • vomiting Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology Objective: Rare disease Background: Sarcoidosis is a multisystem granulomatous disease with predominant pulmonary involvement and rare gastrointestinal (GI) involvement. The stomach is the most common site when there is GI involvement. Symptomatic gastric sarcoidosis with biopsy-proven disease has rarely been reported and much of the knowledge is from case reports involving white patients. Case Report: Our unique case involves a flare of gastric sarcoid in an African American patient with biopsy-proven disease and we highlight our unique broad, multidisciplinary treatment approach that has not been described previously. A 68-year-old woman with pulmonary sarcoidosis presented with epigastric pain, nausea, vomiting, and dysphagia. The diagnosis of gastric sarcoid was made several years prior based on an upper endoscopy biopsy showing non-caseating granulomas in the antrum. She had previously experienced minimal relief of gastric symptoms with corticosteroids. In addition to a steroid taper, the patient experienced improvement in symptoms with a PPI (proton pump inhibitor), bowel regimen, and speech therapy techniques. Conclusions: Gastric symptoms can be a presenting sign for a sarcoid flare in a patient with pulmonary sarcoidosis, which is important for both pulmonologists and gastroenterologists to recognize. In addition to traditional therapy with corticosteroids, our unique broader, multidisciplinary approach with PPI, bowel regimen, and speech therapy techniques such as a liquid wash are important components of treatment for gastric sarcoid that have not been described in previous case reports.

Symptomatic Gastric Sarcoidosis in a Patient with Pulmonary and Neurosarcoidosis: A Case Report

“…We noted the patient continued to be symptomatic after commencing adalimumab but it is unclear whether the frequency, severity, or nature of his symptoms have objectively changed. Suggested approaches include patient journaling to follow the time to toleration of diet and percentage of tolerated diet, as well as the frequency of abdominal pain episodes with use of an abdominal pain scale [ 6 ].…”

“…The inflammation and fibrosis caused by sarcoidosis can result in luminal narrowing, ulceration, or diminished peristalsis. Rarely, patients present with more acute symptoms, such as bleeding or bowel obstruction [ 6 ]. In patients with a previously established diagnosis of sarcoidosis, particularly extrapulmonary sarcoidosis, it is essential to consider new or worsening localized symptoms as progression of disease, and to perform an appropriate diagnostic evaluation.…”

Recurrent small bowel obstruction as a rare presentation of undiagnosed sarcoidosis

“…Evidence for the efficacy of steroids in gastrointestinal sarcoidosis is isolated to case reports. Adjuvant use of motility agents, proton pump inhibitors and speech therapy techniques can also be considered 16. For small bowel sarcoidosis, the majority of reported cases responded well to corticosteroids 17…”

Gastric sarcoidosis diagnosed with endoscopic ultrasound

“…2 In contrast to lung sarcoidosis, gastrointestinal (GI) tract sarcoidosis is rare, presenting in 0.1%-1.6% of cases, with the most common site of affection being the stomach, typically in the antrum. [1][2][3] The most reported symptom is abdominal pain, but nausea, vomiting, anorexia, and early satiety were also reported. 4 The manifestation of gastric sarcoidosis (GS) does not necessarily coincide with pulmonary sarcoidosis.…”

“…Although the systemic involvement with sarcoidosis is highly variable, in almost 90% of the cases, it involves the lungs and hilar lymph nodes, leading to interstitial fibrosis and lymphadenopathy, respectively 1 . Less commonly involved organs include the skin, joints, eyes, heart, kidney, nervous, and digestive systems 2 …”