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ABDOMINAL SARCOIDOSIS: A MYSTERY REVISITED
Nidhi Paswan
*, Lovenish Bains
general surgery, Maulana Azad Medical College, New Delhi, Delhi, India
BACKGROUND
Unexplained lymphadenopathy is a frequently encountered symptom or abnormal finding during physical examinations in practice, and it can stem from a wide range of causes. These require a multitude of investigations to clinch the diagnosis. One of the rare causes is Sarcoidosis, which is a multi-system disease characterized by the infiltration of various organs by non-necrotizing granulomas with intrathoracic involvement being the most common presentation. Its diagnosis presents significant challenges. We describe a case of abdominal sarcoidosis to illustrate this complexity.
METHOD
A 44-year-old woman presented with six months of easy fatigability and dull, aching abdominal pain. She also experienced occasional fever but had no history of tuberculosis exposure or associated symptoms. General examination was unremarkable. Abdominal examination revealed splenomegaly. Ultrasound and subsequent computed tomography showed multiple enlarged lymph nodes in the periportal, peripancreatic, mesenteric, and retroperitoneal regions, along with splenomegaly. Chest imaging revealed no significant findings. Differential diagnoses, including tuberculosis and lymphoma, were initially considered. An EUS-guided biopsy of the abdominal lymph nodes showed features of granulomatous lymphadenitis. However, the diagnosis remained unclear, prompting an FDG PET scan, which revealed findings consistent with those seen on previous imaging.
RESULT
Diagnostic laparoscopy was performed with periportal and peripancreatic lymph node sampling, along with an edge biopsy of the liver. Intraoperatively, multiple nodular hepatic and splenic lesions were identified, along with small, waxy nodules on the parietal peritoneum and enlarged periportal and peripancreatic lymph nodes. Histopathological examination report revealed large non-caseating granulomatous lesions containing epithelioid cells, suggesting sarcoidodis.
DISCUSSION
Extrapulmonary involvement in sarcoidosis occurs in about 30% of patients, with the abdomen being the most common site. Intra-abdominal sarcoidosis, though rare, often presents asymptomatically, making it difficult to diagnose. Its clinical and radiological features are nonspecific and can mimick neoplastic or infectious diseases such as lymphoma, diffuse metastasis, and granulomatous inflammation. In endemic regions of tuberculosis, its presentation can pose significant diagnostic challenges. Liver and spleen are main sites of abdominal sarcoidosis with nodular lesions. Diagnosis relies on clinicopathologic findings and the exclusion of other granulomatous and auto-immune diseases. While often asymptomatic or subtle in presentation, long-standing sarcoidosis can lead to severe complications. Immunosuppressive therapy is the cornerstone of management, highlighting the importance of early identification and monitoring.
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