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Hepatobiliary and pancreatic: Cirrhosis secondary to hepatic sarcoidosis

Sarcoidosis is a granulomatous disorder of unknown etiology. The most commonly affected organs are the lungs and lymph nodes but several other organs can be involved including the liver, skin, eyes, heart and brain. Changes in liver function tests have been reported in 20–50% of patients with a definite diagnosis of sarcoidosis. There is also an interesting subgroup of patients who have liver involvement without overt lung disease, a disorder sometimes called granulomatous hepatitis. With liver involvement, the characteristic histological feature is the presence of non-caseating granulomas within portal tracts and in the periportal zone. With healing, these granulomas can result in periductal fibrosis and a decrease in the number of small bile ducts. The development of cirrhosis and portal hypertension appears to be uncommon but may result from portal inflammation and fibrosis, perhaps associated with phlebitis and thrombosis of portal or hepatic veins. Patients with sarcoidosis and changes in liver function tests are usually treated with corticosteroids and sometimes with immunosuppressive drugs. The duration of therapy is determined by the therapeutic response and the development or otherwise of recurrent symptoms as therapy is tapered. The patient illustrated below was a 29-year-old African American male who was investigated because of a 3 week history of abdominal pain, abdominal distension and fever. On physical examination, he had hepatomegaly, splenomegaly and ascites. Liver function tests revealed a marked elevation in the plasma level of alkaline phosphatase (1461 U/L), with a mild elevation of bilirubin (2 mg/dL or 34 mmol/L) and alanine aminotransferase (63 U/L). His plasma albumin was low at 2.6 g/dL (26 g/L). Various screening tests for other forms of liver disease were negative. A chest x-ray was normal while a computed tomography scan of the abdomen showed hepatomegaly and splenomegaly (Fig. 1) as well as lymphadenopathy and mild ascites. A liver biopsy showed multiple non-caseating granulomas (long arrow), giant cells (short arrow) and extensive fibrosis (Fig. 2). A trichrome (Masson’s) stain confirmed the presence of extensive fibrosis typical of cirrhosis. The patient also had granulomas in a fineneedle aspirate of a supraclavicular lymph node. He was treated with prednisolone, 40 mg per day, but this was only followed by a minor improvement in his symptoms. The subsequent addition of azathioprine resulted in resolution of his symptoms and the return of liver function tests to near-normal. He remains on medication after follow-up for 12 months.