C40-16 The Unexpected Twist of Persistent Nausea and Vomiting: Atypical Presentation of Sarcoidosis

Introduction Sarcoidosis is a multisystem inflammatory granulomatous disease that primarily affects the pulmonary system in up to 90% of cases but may involve extrapulmonary organs. The mechanisms behind its variable organ involvement remain unclear. Gastric sarcoidosis (GS) is an exceptionally rare manifestation and may occur in isolation or with systemic disease, commonly involving the liver and the spleen. The first reported case of GS dates back to 1946. Managing GS with hepatic involvement is challenging due to the complexity of drug selection and dosing adjustments. Case A 42-year-old male marijuana smoker with a history of hypertension and diabetes presented with a six-week history of persistent nausea, vomiting, and a 30-pound unintentional weight loss over 6 months. He had recently completed a two-week course of triple therapy for H. pylori. Laboratory evaluation revealed elevated liver enzymes (T bili 2.1, Alk Phos 1376, AST 92, ALT 125). Immunologic studies showed an elevated angiotensin-converting enzyme (ACE) level of 151, Soluble IL-2 receptor of 4999.8, and weakly positive ANA. CT imaging demonstrated numerous hepatic and splenic masses with moderate hepatosplenomegaly, esophageal thickening, and minimal peripheral reticulonodular opacities. Tumor markers revealed elevated CA19-9 with normal AFP and β-hCG. Infectious workup was significant only for Brucella IgG positivity; all other studies were negative. A transjugular liver biopsy revealed non-necrotizing granulomas without evidence of lymphoproliferative disease. Esophagogastroduodenoscopy showed a normal esophagus with erythematous prepyloric mucosa; gastric biopsies confirmed chronic gastritis with non-necrotizing granuloma, consistent with sarcoidosis. The patient was managed by a multidisciplinary team, involving pulmonary, gastroenterology, and infectious disease specialists. Treatment included prednisone tapered to 10 mg, ursodiol, and a proton pump inhibitor. Liver function tests and symptoms improved with therapy and recurred after steroid withdrawal, necessitating steroid reinitiation and plans for transition to a steroid-sparing agent. Discussion and Conclusion Gastric sarcoidosis is a rare manifestation of systemic sarcoidosis that can mimic other gastrointestinal disorders, such as hepatic sarcoidosis. Diagnosis requires histologic confirmation of noncaseating granulomas after excluding infectious and malignant causes. Corticosteroids remain first-line therapy, though long-term use necessitates transition to immunosuppressive or biologic agents. This case underscores the importance of tissue diagnosis and multidisciplinary management. Further studies and randomized clinical trials are needed to guide therapy for extrathoracic sarcoidosis, particularly gastrointestinal involvement. This abstract is funded by: None