Ramon A Brown, MD, Jason Kempenich, MD. Keesler Medical Center General Surgery Residency Program
Sarcoidosis is a multisystemic granulomatous disease of unknown cause in which more than 90% of patients exhibit mediastinal and hilar lymph node enlargement or parenchymal lung disease. The diagnosis of sarcoidosis is based on compatible clinical and radiographic findings supported by histologic evidence of non-caseating granulomas in one or more organs in the absence of any foreign particles or organisms. Intestinal manifestations of sarcoidosis are rare with few case reports in the literature. Furthermore, the estimated incidence of colonic manifestations is less than 1% of cases involving the gastrointestinal tract. We report a case of a 61-year-old male who presents with colonic polyposis with associated ulcerated non-obstructing mass in the ascending colon found incidentally on screening colonoscopy.
A 61-year-old male with history of colonic polyps presented for routine screening colonoscopy. His past medical history was significant for hypertension and pulmonary sarcoidosis with no active pulmonary sequela. At colonoscopy a 5mm sessile polyp was found adjacent to an infiltrative, ulcerated non-obstructing mass in the mid-ascending colon that encompassed approximately one third of the circumference of the lumen. Biopsies of the mass and the polyp were taken with cold forceps and sent for pathologic analysis. Pathologic diagnosis of the specimens demonstrated a tubular adenoma and chronic inflammation, with granulation tissue with reactive epithelial changes with no evidence of dysplasia or malignancy. A CT scan of the chest abdomen and pelvis was obtained which demonstrated no evidence of metastasis or mesenteric lymphadenopathy; however, calcified mediastinal lymph nodes were present. Preoperative labs were obtained including a carcinoembryonic antigen (CEA) all of which were within normal limits including a CEA of 2.2. At follow-up right hemicolectomy was recommended due to the presence of an endoscopically unresectable mass to rule out malignancy. The patient was taken to the operative theatre for laparoscopic right hemicolectomy with no significant intraoperative or postoperative complications. The pathologic specimen yielded twenty-four lymph nodes with and a 2.2 x 2.2 cm ulcerated mass with rolled borders with in the right colon specimen. The tissue within and around the mass as well as the lymph node samples demonstrated chronic inflammation with well formed, non-caseating granulomas, which were PAS, GMC and AFB negative.
Colonic manifestations of sarcoidosis are rare and its presentation is widely variable, creating a diagnostic dilemma. The management of this disease can be equally perplexing when the disease masquerades as a potentially malignant lesion. Non-operative management of biopsy proven colonic sarcoidosis with systemic corticosteroids is effective. However, in these instances where endoscopy identifies a potential carcinoma, yet pathology fails to rule out malignancy, the surgeon must proceed with the intent to treat cancer with oncologic resection of the affected portion of the colon.