S5284 A Minimally Invasive Approach to Hepatic Sarcoidosis: Diagnosis via Endoscopic Ultrasound-Guided Fine-Needle Biopsy

Introduction: Sarcoidosis is a multi-system inflammatory disease characterized by non-caseating granulomas. Typical manifestation is intrathoracic; however, a subset of patients has prominent hepatic involvement. There is no current consensus on a diagnostic tool for liver biopsy for patients with or suspected of sarcoidosis. We present 2 patients diagnosed with hepatic sarcoidosis using endoscopic ultrasound-guided fine needle biopsy (EUS-FNB). Case Description: Case 1 is a 57-year-old man presented with 10 days of jaundice, pruritus, and choluria with elevated LFTs (ALT 184 IU/L, AST 184 IU/L, ALP 185 IU/L). Hepatitis panel, HIV and cytomegalovirus were negative. Right upper quadrant ultrasound (US) and computed tomography (CT) Abdomen Pelvis indicated hepatic steatosis and prominent nonspecific periportal lymphadenopathy, including a small node in the pancreatic head. EUS with FNB was pursued, and lymph nodes were sampled transduodenally with the 22-gauge (22G) US biopsy needle. Color Doppler imaging was then utilized to confirm a lack of significant vascular structures in the liver, followed by 2 passes (x2) with the 22G US biopsy needle using a transgastric approach (Left Lobe) and transduodenal approach (Right Lobe). Pathology revealed multiple non-necrotizing granulomata, concerning for granulomatous hepatitis. Subsequent chest CT showed hilar and mediastinal adenopathy, confirming a diagnosis of sarcoidosis. The patient started prednisone with improvement of LFTs within a few months. Case 2 is a 41-year-old woman with pulmonary, sinonasal, and ocular sarcoidosis presents with acute RUQ pain and arthralgias with an elevated liver function tests (LFTs) (ALT 38 IU/L, AST 58 IU/L, ALP 594 IU/L). MR abdomen and liver elastography noted prominent abdominal lymph nodes and stage 1 fibrosis. Due to lack of chronic suppressive therapy, hepatic involvement was suspected. Using EUS with FNB, liver tissue sampled using transgastric (x2) and transduodenal approaches (x1) with 19G Acquire biopsy needle. Pathology revealed discrete portal and lobular non-necrotizing epithelioid granuloma confirming hepatic sarcoidosis. Patient was treated with prednisone and adalimumab with improvement in LFTs over the following months. Discussion: Our cases highlight the safety and efficacy of EUS-FNB for liver biopsy in those with or suspected of hepatic sarcoidosis. EUS-FNB can successfully provide both lymph node and liver biopsies despite using a small needle size, displaying its usefulness in multisystem disease diagnosis and adequate specimen size for tissue acquisition.