A 46 year old female with a history of hypertension presented to the ED with recurrent abdominal pain for a month located in the epigastric region and occasionally radiating to the back. She had a weight loss of 20 pounds over the past month. She had normal bowel movement. She quit drinking alcohol 5 years ago and quit smoking a year ago. Examination was unremarkable except for mild tenderness in the upper abdomen. Labs showed a low WBC count of 2 K/uL with absolute neutrophil count of 900 K/uL. She had microcytic anemia with hemoglobin of 9gm/dl and normal platelets. Her lipase was 500 U/L and amylase was 130 U/L. Liver function test showed raised alkaline phosphatase at 140U/L. Immunoglobulin levels were normal. Ultrasound showed heterogeneous and increased echogenicity of liver, pancreas and enlarged spleen. Esophagogastroduodenoscopy with endoscopic ultrasound showed mild inflammation in the gastric antrum which was biopsied and diffuse echogenicity in the entire pancreas with normal ducts. Biopsy of the stomach showed mild chronic inflammation. She was treated conservatively for pancreatitis and her pain improved and was discharged. She underwent colonoscopy with removal of 3 polyps that were tubular adenoma. She then underwent bone marrow biopsy for neutropenia and anemia that showed non caseating granulomas suggestive of sarcoidosis, fungal stains were negative and flow cytometry did not show any lymphoproliferative disorder. Liver biopsy showed non necrotizing granulomatous inflammation with mild portal inflammation. She was started on oral Prednisone 20 mg daily for symptomatic sarcoidosis.
Sarcoidosis is a systemic granulomatous disease characterized by the formation of non caseating granulomas. It involves young adults and most commonly presents as bilateral hilar adenopathy, pulmonary opacities and skin, joint or eye involvement. The most common extrapulmonary sites include the skin, eyes, reticuloendothelial system, exocrine glands, heart, kidney, and central nervous system. The diagnosis of sarcoidosis is made by histopathology demonstrating noncaseating granulomas, exclusion of other causes of granulomatous disease mainly mycobacteria and fungi with documentation of involvement of at least one additional organ system. Only presence of Lofgren’s syndrome, Heerfordt’s syndrome and asymptomatic bilateral hilar adenopathy do not require biopsy for diagnosis. Gastrointestinal (GI) sarcoidosis is very rare. It can involve GI tract, pancreas, and peritoneum. The most common site of GI sarcoidosis is the stomach. Involvement of the pancreas is very rare. It might not have typical presentation of acute pancreatitis. Lipase and amylase might not be as high. Involvement of liver mainly presents as recurrent abdominal pain with nonspecific symptoms. Abnormal labs mainly include high alkaline phosphatase, occasionally increased aminotransferase and hyperbilirubinemia. Generally they improve with oral steroids.
Abdominal pain and pancreatitis is common to Hospitalist practice. It is not uncommon to come across pancreatitis with no known cause. One should try to search for uncommon causes when amylase and lipase are not significantly high but there is still evidence of pancreatitis by symptoms and imaging. It is important to recognize some of the rare causes of pancreatitis that would have been labeled idiopathic in the previous years as treatment differs and maybe effective in curing and controlling the progression of disease.