S6270 A Stomach-Clenching Diagnosis: Gastric Biopsy Unmasks Systemic Sarcoidosis

Introduction: Sarcoidosis is a chronic, non-caseating granulomatous systemic inflammatory disease. It can involve any organ, most commonly the lungs. GI involvement is rare and may present either as part of systemic disease or as an isolated finding. We present an interesting case of gastric sarcoidosis in a woman presenting with epigastric pain and reflux symptoms. Case Description/Methods: A 36-year-old African American woman with no significant past medical history presented to the family medicine clinic with a 4-month history of a chronic, dry cough. She reported no associated fever or weight loss. Her social history was notable for an 8-year history of chronic cigarette use. She denied any recent travel or family history of similar symptoms. In addition to her cough, the patient complained of persistent epigastric pain unrelated to food intake, along with reflux symptoms unresponsive to proton pump inhibitor (PPI) therapy. Initial workup with a complete blood count and complete metabolic profile was unremarkable except for mild anemia (hgb 11.4 g/dL) and low iron saturation (9%). A chest x-ray and PFT were unremarkable. Due to persistent gastrointestinal symptoms and anemia, the patient was referred to gastroenterology. Esophagogastroduodenoscopy revealed a normal esophagus, antral gastritis, and a normal duodenum. Gastric biopsies were obtained. Histopathology of the gastric biopsy revealed noncaseating granulomas, raising suspicion for sarcoidosis, particularly in the context of her chronic cough. The patient was referred to pulmonology and rheumatology for further evaluation. An HRCT scan of the chest revealed mediastinal lymphadenopathy and reticular changes in the left upper lobe. Further lab testing showed an elevated ACE level of 118 U/L, an erythrocyte sedimentation rate of 35 mm/hr, C-reactive protein of 4.5 mg/L. The patient was started on a short course of corticosteroids and initiated on mycophenolate mofetil. After 2 months of therapy, the patient reported significant improvement in both her cough and epigastric pain. Mild reflux symptoms persisted but were well controlled with ongoing PPI therapy. Discussion: Gastric sarcoidosis is a rare manifestation that can mimic other gastrointestinal conditions. Its diagnosis requires careful evaluation, as noncaseating granulomas may also be seen in several other conditions. The differential diagnosis includes peptic ulcer disease, Ménétrier disease, hypertrophic gastritis, infections such as Mycobacterium or Histoplasma, syphilis, gastric malignancies, lymphoma, Langerhans cell histiocytosis, foreign body reactions, Crohn’s disease, and Whipple’s disease. Accurate diagnosis is important, as treatment strategies vary significantly depending on the underlying etiology.