Capsule endoscopy findings in a case of intestinal sarcoidosis

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A 64-year-old man was diagnosed as having sarcoidosis with mediastinal and bilateral axillary adenopathy. Bronchoscopy and purified protein derivative (PPD) skin test were unremarkable. Eleven months later, three to four bilateral small nodules were seen on a chest computed tomography (CT) scan. The patient received no treatment because he was asymptomatic.

Three months later, the patient was admitted with a 3-month history of abdominal discomfort, mainly in the lower abdomen, bloating, diarrhea (four to five loose watery stools/day), weight loss (3 – 4 kg), and fatigue, but no night sweats. Physical examination revealed marginal splenomegaly. Laboratory data showed mild anemia (hemoglobin 11.3 g/dL), with low ferritin and vitamin B₁₂ levels. The angiotensin-converting enzyme (ACE) level was 52 U/L and biochemistry was normal. All other markers for gut malabsorption, including antiendomysial antibodies and immunoelectrophoresis, were normal. Stool studies including Clostridium difficile toxin, fecal leukocytes, cultures, ova and parasites, and random fecal fat were negative.

A colonoscopy revealed edema, granularity, and friability of the terminal ileac mucosa. Gastroduodenoscopy was unremarkable. Terminal ileum biopsies revealed thick lymphoplasmacytic and polymorphonuclear cell infiltration with discrete, noncaseating, epithelioid granulomas containing Langhans giant cells with central necrosis, suggestive of sarcoidosis. Esophageal and gastric biopsies were unremarkable, while duodenal biopsies revealed mild blunting of the villi and lymphoplasmacytic and polymorphonuclear cell infiltration without granulomas.

Capsule endoscopy of the small bowel revealed scarce superficial ulcerative lesions in the distal jejunum ([Fig. 1]) and more confluent ulcers in the ileum.

Fig. 1 a Discrete superficial jejunal ulcer. b Superficial ulcer at the marginal zone between the jejunum and ileum.

In distal ileum, a small number of larger ulcers (diameter 5 – 6 mm) were present on granular mucosa ([Fig. 2]).

Fig. 2 a, b Edema, granulosis, and ulceration in the terminal ileum.

Abdominal CT showed mild splenomegaly, three small hypodense lesions in the spleen, ileac wall thickening, and slight regional lymph node enlargement.

The patient was prescribed prednisolone 30 mg/day. The diarrhea settled within a week, and the lesions seen on capsule endoscopy and colonoscopy regressed within a month of starting the medication. Four months later the dose of prednisolone was tapered, the intestinal disease remained inactive, and the ACE level dropped to 19 U/L.

Endoscopy_UCTN_Code_CCL_1AC_2AH