Post-COVID-19 cholangiopathy: Current understanding and management options

Abstract

Post-coronavirus disease 2019 (COVID-19) cholangiopathy (PCC) is a rare but life-threatening complication of COVID-19 infection. PCC typically presents when patients recovering from the contagion and manifests as cholestasis in patients with no history of pre-existing liver disease. The pathogenesis of PCC is little understood. Hepatic injury in PCC could be mediated by the predilection of severe acute respiratory syndrome coronavirus 2 for cholangiocytes. Though PCC shows some resemblance to secondary sclerosing cholangitis in critically ill patients, it is considered as a separate and unique entity in the literature. Various treatment options like ursodeoxycholic acid, steroids, plasmapheresis, and endoscopic retrograde cholangiopancreatography guided interventions have been tried but with limited success. We have noticed significant improvement in liver function with antiplatelet therapy in a couple of patients. PCC can progress to end-stage liver disease necessitating liver transplantation. In this article, we discuss the current knowledge of PCC focusing on its pathophysiology, clinical manifestations, and management strategies.

Keywords: COVID-19; Cholangiopathy; Cholestasis; Liver; Long haulers; Post-COVID-19 syndrome.

Figure 1

Histopathology imaging. A: Explant liver cut surface with greenish discolouration; B: Explant liver displaying duct loss (arrow) and bilirubinostasis [× 20, hematoxylin and eosin (H&E)]; C: Fibrin thrombi in portal vein (arrow, × 18, H&E); D: Mallory Denk body in a hepatocyte (arrow) and mild lobular inflammation (× 18, H&E); E: CK7 immunostaining with duct loss (arrow) and biliary metaplasia of hepatocytes (× 15); F: Severe acute respiratory syndrome coronavirus 2 immunostaining with granular brown positivity in hepatocytes and macrophages (arrow, × 15).