The presence of granulomas in the liver raises consideration of a wide 
differential diagnosis, but in most Western series, sarcoidosis accounts for a 
majority of cases. This review will focus specifically on the diagnosis of and 
therapy for hepatic sarcoidosis. Sarcoidosis is a systemic granulomatous disease 
of unknown etiology. Hepatic involvement of sarcoidosis was described in 11.5% 
of 736 patients enrolled in the ACCESS study. However, presence alone of 
granulomas in an organ in sarcoidosis does not dictate treatment. The decision 
to treat should be based on symptoms and severity of disease. Although hepatic 
involvement usually is asymptomatic, a minority of patients progress to chronic 
cholestatic disease, portal hypertension, and cirrhosis that may require liver 
transplantation. Treatment of hepatic sarcoidosis should be reserved for 
patients who manifest this spectrum of disease. Glucocorticoid treatment is 
first-line therapy for hepatic sarcoidosis, improving symptoms and abnormal 
laboratory values but generally having no effect on progression of disease. In 
addition to glucocorticoids, immunomodulators such as azathioprine, 
methotrexate, hydroxychloroquine, and infliximab have been used with some 
positive effects on symptoms, liver enzyme abnormalities, and hepatomegaly, but 
none has been shown to prevent progression of disease. Ultimately, in cases of 
overt liver failure, liver transplantation is the definitive treatment. Overall, 
treatment for hepatic sarcoidosis is targeted toward alleviation of symptoms but 
has no curative potential at this time. Focus should be on discovering the 
etiology of the disease to target therapy at prevention, not cure.