Abdominal Sarcoidosis: A Mystery Revisited

Unexplained lymphadenopathy is an often-encountered symptom or abnormal finding during physical examinations in practice, and it can stem from a wide range of causes. These require multiple investigations to reach a 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. It has a global prevalence of approximately 5-64 cases per 100,000 people, depending on the region. Abdominal sarcoidosis accounts for approximately 30% of extrapulmonary manifestations. Its diagnosis presents significant challenges. We describe a case of abdominal sarcoidosis and the role of laparoscopy in diagnosis. A 44-year-old woman presented with 6 months of easy fatigability and dull, aching abdominal pain. She also experienced occasional fever but had no history of tuberculosis exposure or associated symptoms. The general examination was unremarkable. Abdominal examination revealed splenomegaly. Ultrasound and subsequent computed tomography showed multiple enlarged lymph nodes (LNs) in the periportal, peripancreatic, mesenteric, and retroperitoneal regions, along with splenomegaly. Chest imaging revealed no significant findings. Differential diagnosis, including tuberculosis and lymphoma, was initially considered. An EUS-guided biopsy of the abdominal LNs 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. Diagnostic laparoscopy was performed with periportal and peripancreatic LN 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 LNs. Histopathological examination report revealed large non-caseating granulomatous lesions containing epithelioid cells, suggesting sarcoidosis. Intra-abdominal sarcoidosis, though rare, often presents asymptomatically, making it difficult to diagnose. Its clinical and radiological features are nonspecific and can mimic neoplastic or infectious diseases. In endemic regions of tuberculosis, its presentation can pose significant diagnostic challenges. Diagnosis relies on clinicopathologic findings and the exclusion of other granulomatous and autoimmune diseases. Diagnostic laparoscopy is required to reveal the involvement of granulomatous disease in the visceral and parietal peritoneum and reach a histopathological diagnosis. Especially in cases of isolated abdominal sarcoidosis, diagnostic laparoscopy played an important role in forming a definitive diagnosis.