Copyright ©The Author(s) 2023.
World J Gastrointest Surg. May 27, 2023; 15(5): 788-798
Published online May 27, 2023. doi: 10.4240/wjgs.v15.i5.788
Table 1 A summary of reported cases of post-coronavirus disease 2019 cholangiopathy in the literature
Number of patients
Age, median (range)
Time interval between COVID-19 diagnosis and presentation with features of PCC
Peak bilirubin (mg/dL)
Peak ALP (U/L)
Outcome reported
Edwards et al[21], 2020159MaleTime to elevation of bilirubin: 15 d. Peak at 79 d14.64000Beading of intrahepatic ductsNot reportedERCP for sludge clearanceAlive (planning biopsy to decide on liver transplantation)
Roth et al[13], 2021334 (25-40)2 males, 1 femaleAround 6 mo Patient 1-7 gm/dL, patient 2-24 and patient 3-1516 × ULNTwo of three: Hepatomegaly. One of three: Extrahepatic bile ducts dilatation and one of three: Intrahepatic bile ducts strictures and dilatations with beaded aspect or solely dilatationTwo of three: Mild and moderate bile ducts paucity. Three of three moderate ductular reaction, cholangiocytes swelling and regenerative changes with portal tract inflammation, hepatic artery endothelial swelling, hepatic veins endophlebitis and periportal fibrosisConservativeTwo patients discharged home, one still hospitalized
Faruqui et al[22], 20211258 (38-73)Male: 92%; female: 8%Mean interval-118 dRange: 2-35Range: 965-2544Eleven of twelve patents showed beaded images of intrahepatic bile ducts, seven of twelve patients showed bile ducts thickening and hyperenhancement, ten of twelve patients showed peribiliary diffusion high signalPerformed in four of twelve pts. Acute or chronic large bile ducts obstruction, mild fibrosis of some portal tracts, Keratin 7 immunostain positivityUDCA. UDCA slightly improved some lab tests (AST and ALT) but GGT and ALP remained elevatedFour of twelve died for complications consequent to sclerosing cholangiopathy, 2/12 listed for transplantation, 5/12 continuing conservative management
Durazo et al[27], 2021147MaleAround 2 mo191644Mild intrahepatic bile ducts dilatation with focal strictures and beaded aspect, no dilatation of CBDInflammatory mononuclear infiltrates of bile ducts walls with increased collagen deposition, liver abscesses and bile lakes associated with bile duct injury with vacuolization and neutrophilia. Endothelial cell swelling, lumen obliteration of arterial vessels and obliterative portal venopathyLiver transplantationAlive with normal LFT at 7 mo after liver transplantation
Tafreshi et al[42], 2021138MaleCholestasis at a few months after initial hospital admission9.83665Mild dilatation of intrahepatic bile ducts with beaded aspect, dilatation of CBD and periportal oedemaCholangiocytes injury, ductular proliferation, canalicular cholestasis, a bile lake and focal bridging fibrosisUnder evaluation for liver transplantationUnder evaluation for liver transplantation
Lee et al[38], 2021164Male51 d7.81600Mild intrahepatic biliary ductal dilatation and mild patchy T2 hyperintensity within the right hemiliver, concerning for cholangitisExplant pathology: Bridging fibrosis, severe bile duct injury, ductular reaction and leucocytes and plasma cells infiltrateLiver transplantation Alive at 8 mo and returned to work
Klindt et al[43], 2021147MaleAround 50 d18 1700Alterations of medium and small intrahepatic bile ductsEnlarged portal tracts with phlogistic infiltrate, ductular reaction with degenerative alterations of bile duct epithelium; focal biliary metaplasia of periportal hepatocytes. A few bile infarcts and perivenular canalicular cholestasisLiver transplantationAlive
Rojas et al[44], 2021129FemaleAround 2 mo196000Only a cystic lesion in liver segment VLow periportal phlogistic infiltrate without necrosis but with a severe obstructive cholestatic patternUDCA and cholestyramineSlight improvement at the time of reporting
Bütikofer et al[28], 2021459 (54-67)Male: 3, female: 170-153 d3.81-26.05(12.85-21.26) × ULNDiffuse irregularities of the bile ducts with dilatations and stricturesPortal inflammation with pericellular fibrosisUDCA2 patients: Deceased. 1 patient: Listed for liver transplantation (MELD-17). 1 patient: Persistently marked increased ALP and GGT at 9 mo of follow up
Rela et al[16], 2022150Male4 wk42.4248Mild prominence of central intrahepatic, common hepatic, and common bile ducts with minimal beading of the right posterior sectoral and segment 2 ductsMild portal tract inflammation with lymphocytes, histiocytes and few eosinophils, with loss of interlobular bile ductsAuxiliary partial orthotopic liver transplantationAsymptomatic at 6 mo follow-up with good graft function and recovering function in native liver remnant
Kulkarni et al[17], 202215Unvaccinated: 59 (24-67). Vaccinated: 52 (29-67)Unvaccinated: Male (8/8, 100%). Vaccinated: Male (5/7, 71.4%)The median time to the development of cholestasis was 35 (19-44) d and in vaccinated group and 39.5 (27-57) in the unvaccinated groupUnvaccinated group: 22.95 (4.2-48.5), vaccinated group 17 (8.3-32.4)312 (239-517) U/L in the vaccinated group and 571.5 (368-1058) U/L in the unvaccinated groupNormal in all patientsArchitectural distortion, fibrosis, cholestasis, and ductular reaction with duct openia in unvaccinated group. Cholestasis and inflammation and no fibrosis in vaccinated groupUDCA. Plasma exchange: 5. Oral steroids: 42-died. 2-liver transplantation. 2-listed for liver transplantation. 1-declined liver transplantation. 2-recovered. All 7 in vaccinated group recovered
Mayorquín-Aguilar et al[45], 2022346 (45-52)Male12-14 wk in two patients and 20 d in another patient17.32 (5.8-22.7)1328 (705-1695)Irregular morphology of intrahepatic and extrahepatic bile ducts. Multiple areas of stenosis in the distal intrahepatic bile ductsIntracanalicular cholestasis, portal inflammation, ductular reaction, and moderate portal fibrosisUDCA, cholestyramine, and sertralinePersisitent cholestasis in one patient and disease progressed to cirrhosis in another patient. Third patient expired due to unrelated cause
Hunyady et al[37], 20232457 (19-73)Out of 24 patients, 20 were male, 4 females 91 d (IQR: 64-154 d)Peak bilirubin 24.3 mg/dL. Median bilirubin 11.9 mg/dL (6.0-24.3)Peak ALP 1100 U/L. Median ALP 925 U/L. (555-1100)Strictures or dilatation of biliary system, rarefication of biliary tree including contrast filling defects or detection of biliary casts- UDCA in 16 (66.7%) patients, ERCP with sphincterotomy done in 20 (83.3%) patients. Cast extraction done in 11 (45.8% patients). 3 patients underwent liver transplantation3 patients underwent liver transplantation. 2 patients had transplant free survival
Table 2 A summary of authors’ experience with post coronavirus disease 2019 cholangiopathy
ICU admission for COVID
Mechanical ventilation for COVID
Medications received for COVID
LFT at initial admission for COVID
LFT (peak values)
Time interval1     
167/maleYes (hypoxia-high flow oxygen)NoRemdesivir, methylprednisoloneBilirubin 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/dLBilirubin 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 0.984 wkNormal except for cholelithiasisMild portal fibrous expansion with diffuse loss of interlobular bile ductsPrednisolone, ursodeoxycholic acidHyperbilirubinemia continued to worsen. Expired of pneumonia
250/maleYesYesMethylprednisolone, Remdesivir, antibiotics and thromboprophylaxisBilirubin 0.5 mg/dL, AST 43 U/L, ALT 57 U/L, ALP 60 U/L, GGT 64 U/L, albumin 2.8 mg/dLBilirubin 31.3 mg/dL, ALP 248 U/L, GGT 355 U/L, AST 176 U/L and ALT 200 U/L6 wkMild prominence of central intrahepatic, common hepatic, and common bile ducts with minimal beading of the right posterior sectoral and segment 2 ductsMild portal tract inflammation with lymphocytes, histiocytes and few eosinophils, with loss of interlobular bile ductsAuxiliary partial orthotopic liver transplantationAsymptomatic at 6 mo follow-up with good graft function and recovering function in native liver remnant
358/maleNoNoDoxycycline, ivermectin, methylprednisolone. Remdesivir, paracetamol along with zinc and other vitamin supplementsBilirubin 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/dLBilirubin 10 mg/dL, AST 167 U/L, ALT 181 U/L, ALP 532 U/L and GGT 728 U/L6 wkNormalBile duct degenerative changes in majority of portal tracts along with prominent centrilobular hepatocanalicular bilirubinostasisAspirin, clopidogrel, prednisolone, ursodeoxycholic acidImproved, LFT at 18 mo of follow up. Bilirubin 1.3 mg/dL, AST 101 U/L, ALT 101 U/L, ALP 309 U/L
452/maleYesYesAmoxycillin, remedesivir, IV methyl prednisoloneBilirubin 1 mg/dL, albumin 4.2 g/dL, ALT 25 U/L, AST 49 U/L, ALP 110 U/L, GGT 62 U/LBilirubin 33.9 mg/dL ALP 390 U/L, ALT 41 U/L, GGT 94 U/L, AST 58 U/L6 wkNormalBile ducts showed mild injury, lobular bilrubinostasisTherapeutic plasma exchange, aspirin, clopidogrel, prednisolone, ursodeoxycholic acidImproved, LFT at 6 mo of follow up. Bilirubin 1.1 mg/dL, ALP 101 U/L, AST 23 U/L, ALT 32 U/L