Cholestatic Injury Associated With Biliary Tract Inflammation May Be a Late Complication of Severe COVID-19

Primary sclerosing cholangitis (PSC). This chronic cholestatic liver disease is characterised by an inflammation and fibrosis of the biliary tracts.
Investigators described a syndrome of cholangiopathy in patients recovering from severe COVID-19 with abnormal liver tests and bile duct injury.

During recovery from severe COVID-19, patients may develop cholestatic injury associated with biliary tract inflammation, which might resemble sclerosing cholangitis, according to study results published in The American Journal of Gastroenterology.

Although COVID-19 is predominantly associated with respiratory tract infection, it is also frequently associated with abnormal liver tests, namely transaminase elevations; however, there are no disease-specific lesions on biopsy.

A team of investigators from New York University Grossman School of Medicine in New York conducted a retrospective review of patients with COVID-19 who were admitted to hospital from March 1, 2020 to August 15, 2020 and found to have abnormal liver test results. “We describe a syndrome of cholangiopathy in patients recovering from severe COVID-19 characterized by marked elevation in serum alkaline phosphatase (ALP) accompanied by evidence of bile duct injury on imaging,” the authors wrote.

Of the 2047 patients who were admitted to their institution with COVID-19, 12 patients (0.59%; mean age, 58 years) were recovering from severe COVID-19 and presented with abnormal biochemical findings that suggested cholestatic liver injury. Of these patients, 11 were men, and 9 had a history of hypertension before admission. In addition, 5 patients had obesity and 5 had a history of diabetes; however, only 1 patient had a chronic liver disease diagnosis upon previous imaging. All 12 patients had pneumonia, sepsis during hospitalization, and required mechanical ventilation.

The mean time from COVID-19 to cholangiopathy diagnosis was 118 days. The peak median laboratory values for serum alanine aminotransferase and median serum ALP were 661 U/L and 1945 U/L, respectively. Total bilirubin was 13 mg/dL. Elevations in inflammatory markers were also observed, with peak median C-reactive protein levels of 360 mg/L and an erythrocyte sedimentation rate of 120 mm/hr. The median peak creatinine was 6.5 mg/dL and half of the patient population had peak levels of D-dimers greater than 10,000 ng/mL.

On magnetic resonance cholangiopancreatography, 92% of patients had beading of intrahepatic ducts, 58% had bile duct wall thickening with enhancement, and 83% had peribiliary diffusion high signal.

Of the 4 patients who underwent liver biopsies, no significant differences in cholangiopathy presentation were noted, compared with patients who did not undergo biopsy. However, all the specimens showed similar features of acute and/or chronic large duct obstruction without definitive bile duct loss.

A total of 4 patients died, 1 of which was listed for liver transplant at an outside institution. Five patients had a referral for consideration for liver transplant and 1 patient underwent living donor liver transplantation and recovered well.

“Our observations raise important concerns about long-term morbidity and late complications, including the potential need for liver transplantation or mortality engendered by this syndrome,” the authors noted.  “COVID cholangiopathy is an important complication of SARS-CoV-2 infection that requires further study on its natural history and potential preventive or therapeutic interventions,” the investigators concluded.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Faruqui S, Okoli FC, Olsen SK, et al. Cholangiopathy after severe COVID-19: clinical features and prognostic implications. Am J Gastroenterol. 2021;116(7):1414-1425. doi:10.14309/ajg.0000000000001264

This article originally appeared on Gastroenterology Advisor