Hepatic Involvement in Systemic Sarcoidosis

Current concepts on pathogenesis, diagnosis and management of hepatic sarcoidosis

Sarcoidosis is an inflammatory multisystemic granulomatosis of unknown cause, with a wide range of clinical features, characterized by the presence of non-caseating granulomas. Liver is the third involved organ after lungs and lymph nodes, with a reported prevalence of hepatic involvement in 5 to 25% of systemic symptomatic sarcoidosis. The immunopathogenesis of sarcoidosis is still unknown but it seems to involve the innate and adaptive immune actors in response to a putative antigen in genetically predisposed individuals. Because of its paucisymptomatic presentation, hepatic sarcoidosis may be underdiagnosed. Unspecified impaired general condition, fever, abdominal pain, and jaundice are the main symptoms associated with liver sarcoidosis. Frequently, laboratory liver tests are abnormal. Imaging tools may reveal liver nodular enlargement but can be totally normal. Liver biopsy is often required to confirm the diagnosis. A meticulous workup is mandatory to rule out differential diagnosis of hepatic granuloma. Portal hypertension and liver cirrhosis are the most prevalent complications of hepatic sarcoidosis. Treatment is not necessary in all cases and first line treatment in symptomatic patients requires corticosteroids and/or ursodeoxycholic acid. Immunosuppressants and biologics could be used as second line agents. In severe cases, liver transplantation is indicated.

The clinical management of hepatic sarcoidosis: A systematic review

Background

Hepatic sarcoidosis is an uncommon clinical condition in which clear recommendations are lacking in its treatment. We aimed to review systematically the literature on hepatic sarcoidosis treatment to guide clinicians.

Methods

Using MEDLINE, PubMed, CINAHL, Cochrane Library, and Google Scholar databases, we searched original articles on clinical studies reporting the outcome of adult hepatic sarcoidosis patients following treatment with various pharmacological agents. The primary end point was focused on assessing symptomatic relief and biochemical improvement posttreatment.

Results

Out of 614 retrieved references, 34 published studies were eligible, providing data for a total of 268 patients with hepatic sarcoidosis. First-line therapy with corticosteroids alone was reported in 187 patients, whilst ursodeoxycholic acid (UDCA) was used in 40 patients. Symptomatic and biochemical responses were reported among 113(60.4%) and 80(42.8%) cases of corticosteroids respectively, whereas UDCA showed a complete response in 23(57.5%) patients. Second-line therapy was used in steroid-refractory cases, with most cases being reported for azathioprine (n = 32) and methotrexate (n = 28). Notably, 15(46.9%) and 11(39.2%) patients showed both clinical and biochemical responses respectively. Biological therapy including anti-tumor necrosis factor (anti-TNF) was used as third line therapy in twelve cases with a 72.7% symptomatic and biochemical response rate each.

Conclusion

The quality of evidence for the treatment of hepatic sarcoidosis was poor. Nevertheless, it appears that corticosteroid or UDCA may be utilized as first-line therapy. For cases that are refractory to corticosteroids, steroid-sparing immunosuppressive agents and anti-TNF have shown some promising results, but further high-quality studies are required.