EP846 - Title: Sarcoidosis of the Colon, an Atypical Presentation of Systemic Sarcoidosis

Purpose/Background: The patient is a 64-year-old female with a past medical history significant for sarcoidosis and diverticulitis as well as an extensive surgical history including distal gastrectomy with Roux-en-Y reconstruction who presented with lower abdominal pain. Her abdominal pain was associated with intermittent cramping, constipation and weight loss. During hospitalization for diverticulitis, CT of the abdomen and pelvis with IV contrast demonstrated abscess formation and tethering of the sigmoid colon to the bladder dome. Repeat CT, after conservative management, demonstrated an increase in size of previously noted diverticular abscess as well as new diffuse colonic wall thickening concerning for colitis.

Methods/Interventions: The patient underwent an open sigmoid colectomy. A greater than 5-hour adhesiolysis was required to safely mobilize the colon for resection. The sigmoid colon was indurated, thickened, and plastered to the pelvic sidewall with an underlying chronic abscess cavity. After resection of the sigmoid colon, an anastomosis was created between the remaining descending colon and rectum. Due to her history of significant weight loss and extensive adhesive disease, the decision was made to perform loop ileostomy to protect the anastomosis. The resected sigmoid colon, portion of the rectum, and anastomotic rings were sent to surgical pathology.

Results/Outcomes: Postoperatively, surgery was complicated by a month-long hospitalization due to challenges with pain control, prolonged ileus, protein calorie malnutrition requiring TPN, and subsequent high ileostomy output leading to acute kidney injury. Surgical pathology showed small, well-formed non-necrotizing granulomas as well as asteroid bodies and giant cells in the colon and rectum consistent with sarcoidosis. She was discharged with plans to follow closely with colorectal team as well as pulmonology for ongoing management of sarcoidosis.

Conclusion/Discussion: Gastrointestinal involvement in sarcoidosis is exceedingly rare with most cases affecting the stomach or the small intestine. Colonic involvement has been documented in only a handful of reports. In previous cases, the presentation of colonic sarcoidosis was variable and nonspecific with symptoms often overlapping those of malignancy. For instance, two cases presented as bloating, a change in stool caliber, weight loss, and a right lower quadrant lesion on endoscopy that was concerning for malignancy but ultimately diagnosed as sarcoidosis following right hemicolectomy. For this patient, the complex history of chronic diverticulitis and prior GI resections obscured both clinical and radiographic findings of colonic sarcoidosis. Additionally, her recent surgical history has significant implications for treatment. The standard treatment for sarcoidosis is corticosteroid therapy; however, the ideal regimen for colonic involvement is not known. Additionally, corticosteroid use in the recent postoperative period leaves her at increased risk of infection and anastomotic complications. It is also worth considering how preoperative treatment with corticosteroids may have better optimized the patient for surgery and improved her recovery postoperatively. The patient will require close follow up with a multidisciplinary team and periodic imaging to monitor progression of disease.

Figure 1
Preoperative CT demonstrating abscess and colonic thickening.