A patient presented with 5 days of upper abdominal pain. A blood test showed elevated infection counts and alkaline phosphatase. An abdominal ultrasound was made because cholecystitis was suspected. Because of the findings on ultrasound, computed tomography (CT) of thorax and abdomen was made.
The abdominal ultrasound, supplemented with intravenous contrast, showed a thin-walled gallbladder with multiple gallstones but no signs of cholecystitis. Moreover, the ultrasound of the abdomen showed hepatomegaly and splenomegaly and multiples hypodense/hypovascular lesions/nodules scattered in both liver and spleen. The findings were confirmed on a contrast-enhanced CT scan of the abdomen.
In addition, thoracic CT showed mediastinal lymphadenopathy and reticulonodular opacities scattered in both lungs.
Sarcoidosis is a systemic inflammatory disease of unknown aetiology. It is characterized by non-caseating epithelioid granulomas that may affect any organ system. Patients between 20 and 40 years of age are most commonly affected. The clinical presentation varies. Patients can be asymptomatic, they can have systemic symptoms (fever, weight loss, fatigue etc.) or/and organ-specific symptoms (e.g. coughing). 
Abdominal organs are less frequent involved than pulmonary and mediastinal disease. Pulmonary involvement includes about 90 % and abdominal involvement about 10 % of patients with sarcoidosis. The most frequently involved abdominal organs are liver and spleen. 
The diagnosis of sarcoidosis depends on clinical and radiological presentation and histopathological evidence of non-caseating granulomas. 
In this case, the sarcoidosis diagnosis was an incidental finding. The abdominal ultrasound found gallstones in the gallbladder that could explain his acute abdominal pain. When sarcoidosis was suspected in the patient, he was asked if he had other symptoms of disease. He added that he had suffered from fatigue, shortness of breath, and coughing for a longer period of time. Moreover, he had cutaneous involvement with erythema nodosum - a skin biopsy showed non-caseating granulomas. The patient is being treated with prednisolone and methrotrexate with good effect.
This case was brought up to draw attention to the ultrasound and CT findings of intra-abdominal sarcoidosis to prevent unrecognized disease.
Differential Diagnosis List
Infectious disease (e.g. tuberculosis