Atypical Presentation of Colonic Sarcoidosis and Current Diagnostic Challenges

We present a case of a Hispanic woman in her 70s who presented with nonspecific lower abdominal pain leading to a diagnosis of hepatic and colonic sarcoidosis. She had elevated liver function tests (LFTs), and imaging ruled out ischemia and cholangitis but revealed a cecal and ascending colon wall thickening with fat stranding. Infectious and autoimmune causes of elevated LFTs were excluded. A liver biopsy showed noncaseating granulomas, indicating hepatic sarcoidosis. Despite no bloody diarrhea, a colonoscopy was performed due to nonspecific abdominal pain and imaging-based evidence of colitis. A colonoscopy revealed diffuse areas of severely erythematous, hyperemic, and ulcerating mucosa in the ascending colon. Biopsies confirmed abundant noncaseating granulomas in the background of inflammation. Stool testing, imaging, and staining of biopsies excluded infectious or ischemic etiologies of colitis. The presence of hepatic sarcoidosis, along with age and symptom profile, prompted a diagnosis of colonic sarcoidosis rather than Crohn's colitis. Prednisone and methotrexate improved her symptoms and LFTs within 3 months of initiation.