Abdominal sarcoidosis: cross-sectional imaging findings

Abstract

Sarcoidosis is a multisystem inflammatory disease of unknown etiology. The lungs and the lymphoid system are the most commonly involved organs. Extrapulmonary involvement is reported in 30% of patients, and the abdomen is the most common extrapulmonary site with a frequency of 50%-70%. Although intra-abdominal sarcoidosis is usually asymptomatic, its presence may affect the prognosis and treatment options. The lesions are less characteristic and may mimick neoplastic or infectious diseases such as lymphoma, diffuse metastasis, and granulomatous inflammation. The liver and spleen are the most common abdominal sites of involvement. Sarcoidosis of the gastrointestinal system, pancreas, and kidneys are extremely rare. Adenopathy which is most commonly found in the porta hepatis, exudative ascites, and multiple granulomatous nodules studding the peritoneum are the reported manifestations of abdominal sarcoidosis. Since abdominal sarcoidosis is less common and long-standing, unrecognized disease can result in significant morbidity and mortality. Imaging contributes to diagnosis and management of intra-abdominal sarcoidosis. In this report we reviewed the cross-sectional imaging findings of hepatobiliary, gastrointestinal, and genitourinary sarcoidosis.

Figure 1.

Axial US image of a 59-year-old female with biopsy-proven hepatic sarcoidosis demonstrates innumerable, diffusely distributed hypoechoic granulomas (dashed arrows) in an enlarged hyperechoic liver. A periportal hypoechoic enlarged lymph node (arrows) is also detected at the hilum of the liver.

Figure 2.

Axial contrast-enhanced CT image of a 23-year-old female with biopsy-proven hepatosplenic sarcoidosis shows coalescence of granulomas in the form of large, geographic, hypoechoic, hypodense areas in an enlarged liver and the spleen.

Figure 3.

Liver US of a 52-year-old female demonstrates three hypoechoic nodules (arrows) in the right lobe of the liver representing noncaseating granulomas proven by biopsy.

Figure 4. a, b.

A 41-year-old female with biopsy-proven hepatosplenic sarcoidosis. Contrast-enhanced axial CT image (a) and follow-up CT examination after three years (b). Contour irregularity of the shrinking liver became prominent within three years (b, arrows).

Figure 5. a, b.

A 50-year-old female with biopsy-proven hepatosplenic sarcoidosis. T2-weighted fat-saturated images show hypointense lesions in the liver and spleen (a). The lesions enhance less than the background liver on gadolinium-enhanced T1-weighted images (b).

Figure 6.

Sagittal US image of a 59-year-old female with proven splenic sarcoidosis shows a 3.5 cm hypoechoic, focal lesion (arrow) in an enlarged spleen, due to a noncaseating granuloma.

Figure 7. a, b.

A 45-year-old female with proven splenic sarcoidosis. Contrast-enhanced CT of the abdomen shows multiple hypodense granulomas infiltrating the enlarged spleen (a). Contour irregularity of the shrinking spleen became prominent within six-years follow-up (b, arrows).

Figure 8. a–c.

Barium small bowel follow-through (a) shows mucosal irregularity, nodularity, and angulation of terminal ileum and ileocecal region (arrow) in a 62-year-old female patient with biopsy-proven sarcoidosis. Subsequent contrast-enhanced CT examination (b) demonstrates multiple lymph nodes in the mesenteric root (arrows). Panel (c) shows wall thickening of the caecum (dashed arrow), heterogeneous hyperdensity of the omentum (arrows) and mesenteric free fluid (open arrows).

Figure 9. a–c.

Contrast-enhanced abdominal CT of a 38-year-old male suffering from cough and abdominal pain. Enlarged lymph nodes in the mesenteric root (a, arrows), a markedly enlarged appendix with thickening of the wall (b, c, arrows) and thickening of the caecal apex (c, open arrow) are seen. Bronchoscopic and colonoscopic biopsies revealed chronic granulomatous inflammation confirming the diagnosis of pulmonary and gastrointestinal sarcoidosis.

Figure 10. a, b.

A 62-year-old female with biopsy-proven abdominal sarcoidosis. Contrast-enhanced CT of the abdomen shows peripancreatic (a) and pericecal (b) enlarged hypodense lymph nodes with peripheral and heterogeneous enhancement.

Figure 11.

A 58-year-old female with biopsy-proven abdominal sarcoidosis. Gadolinium-enhanced T1-weighted image shows enlarged and discrete lymph nodes smaller than 2 cm in diameter detected in the porta hepatis, peripancreatic region, and celiac axis (arrows).

Figure 12. a, b.

A 63-year-old female with biopsy-proven pancreatic sarcoidosis. Contrast-enhanced CT of the abdomen (a) shows enlarged lobulated pancreas. Ill-defined multiple small hypodense lesions are detected in the pancreatic head and body (b, arrows).

Figure 13. a–d.

A 57-year-old female with biopsy-proven hepatic, splenic, and renal sarcoidosis. Contrast-enhanced CT of the abdomen (a, b) shows multiple hypodense granulomas infiltrating the liver and spleen. Small hypodense granulomas are also detected in both kidneys (a, b, arrows). Contour irregularity of the shrinking liver became prominent (c, dashed arrows) and contour irregularity of the right kidney at the site of granuloma occurred (d, dashed arrow) at five-month follow-up.

Figure 14.

A 30-year-old male with testicular sarcoidosis proven by partial removal of the testis. B-mode and color Doppler US shows scrotal swelling and hypoechoic nodular areas in the left testis (arrows).

Figure 15. a, b.

A 30-year-old male with biopsy-proven sarcoidosis. B-mode and color Doppler US of the testis shows nodular thickening of the tunica vaginalis (a, arrow) and of the head of the epidydimis (b).

Figure 16.

A 21-year-old male with extra-testicular sarcoidosis proven by biopsy. US shows infiltration around the vas deferens (arrows), at the lower pole of the scrotum, which disappeared after treatment. The patient also had neurosarcoidosis.