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

Table 2 A summary of authors’ experience with post coronavirus disease 2019 cholangiopathy

Case	Age/sex	ICU admission for COVID	Mechanical ventilation for COVID	Medications received for COVID	LFT at initial admission for COVID	LFT (peak values)	Time interval1	MRCP	Biopsy	Treatment	Outcome
1	67/male	Yes (hypoxia-high flow oxygen)	No	Remdesivir, methylprednisolone	Bilirubin 0.84 mg/dL, AST 54 U/L, ALT 32 U/L, ALP 127 U/L, GGT 78 U/L and albumin 4.1 mg/dL	Bilirubin 12.7 mg/dL, AST 322 U/L, ALT 527 U/L, ALP 474 U/L and GGT 1318 U/L, albumin 3.2 g/dL, INR 0.98	4 wk	Normal except for cholelithiasis	Mild portal fibrous expansion with diffuse loss of interlobular bile ducts	Prednisolone, ursodeoxycholic acid	Hyperbilirubinemia continued to worsen. Expired of pneumonia
2	50/male	Yes	Yes	Methylprednisolone, Remdesivir, antibiotics and thromboprophylaxis	Bilirubin 0.5 mg/dL, AST 43 U/L, ALT 57 U/L, ALP 60 U/L, GGT 64 U/L, albumin 2.8 mg/dL	Bilirubin 31.3 mg/dL, ALP 248 U/L, GGT 355 U/L, AST 176 U/L and ALT 200 U/L	6 wk	Mild prominence of central intrahepatic, common hepatic, and common bile ducts with minimal beading of the right posterior sectoral and segment 2 ducts	Mild portal tract inflammation with lymphocytes, histiocytes and few eosinophils, with loss of interlobular bile ducts	Auxiliary partial orthotopic liver transplantation	Asymptomatic at 6 mo follow-up with good graft function and recovering function in native liver remnant
3	58/male	No	No	Doxycycline, ivermectin, methylprednisolone. Remdesivir, paracetamol along with zinc and other vitamin supplements	Bilirubin 1.99 mg/dL, AST 145 U/L, ALT 140 U/L, ALP 70 U/L, GGT 65 U/L and albumin 4.1 g/dL	Bilirubin 10 mg/dL, AST 167 U/L, ALT 181 U/L, ALP 532 U/L and GGT 728 U/L	6 wk	Normal	Bile duct degenerative changes in majority of portal tracts along with prominent centrilobular hepatocanalicular bilirubinostasis	Aspirin, clopidogrel, prednisolone, ursodeoxycholic acid	Improved, LFT at 18 mo of follow up. Bilirubin 1.3 mg/dL, AST 101 U/L, ALT 101 U/L, ALP 309 U/L
4	52/male	Yes	Yes	Amoxycillin, remedesivir, IV methyl prednisolone	Bilirubin 1 mg/dL, albumin 4.2 g/dL, ALT 25 U/L, AST 49 U/L, ALP 110 U/L, GGT 62 U/L	Bilirubin 33.9 mg/dL ALP 390 U/L, ALT 41 U/L, GGT 94 U/L, AST 58 U/L	6 wk	Normal	Bile ducts showed mild injury, lobular bilrubinostasis	Therapeutic plasma exchange, aspirin, clopidogrel, prednisolone, ursodeoxycholic acid	Improved, LFT at 6 mo of follow up. Bilirubin 1.1 mg/dL, ALP 101 U/L, AST 23 U/L, ALT 32 U/L

¹Time interval between coronavirus disease 2019 (COVID-19) diagnosis and presentation with features of post-COVID-19 cholangiopathy.

COVID: Coronavirus disease; ALP: Alkaline phosphatase; GGT: Gamma glutamyl transpeptidase; MELD: Model for end-stage liver disease; LFT: Liver function test; MRCP: Magnetic resonance cholangiopancreatography; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; ICU: Intensive care unit; INR: International normalized ratio.