New York Institute of Technology College of Osteopathic Medicine Old Westbury, NY, United States
Amina Kureshi, 1, Eleazer Yousefzadeh, MD2 1New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY; 2New York Institute of Technology College of Osteopathic Medicine, Garden City, NY
Introduction: Post-COVID cholangiopathy is a novel sequela discovered in patients who have undergone long ICU admissions. Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) has been described prior to COVID as resulting from ischemic injury and is progressive, only cured with liver transplantation. Here the authors present the diagnosis of developing SSC-CIP with downtrending liver markers.
Case Description/Methods: A previously healthy 46-year-old man presented to the ED with shortness of breath, positive for COVID, and met sepsis criteria. After admission the patient quickly deteriorated, was admitted to ICU for acute hypoxic respiratory failure where extracorporeal membrane oxygenation (ECMO) was initiated. What continued was a 40+ day ICU stay for drug resistant bacteremia, candidemia, multiple recurrent pneumothoraces / hemothoraces, two episodes of GI bleeds, multiple transfusions, and adrenal insufficiency.
Liver markers started to elevate in the setting of benign ultrasound and abdominal CT. Transaminitis (peaking at around 1,300 ALT, 935 AST, 2,700 alk phos) persisted despite antifungal discontinuation.
MRCP: Multiple areas of irregular intrahepatic ductal narrowing with beading and small pockets of fluid adjacent to the ducts. No extrahepatic ductal abnormalities. Findings are likely related to cholangitis.
ERCP: Beading of the intrahepatic biliary system.
Liver Biopsy: Acute and chronic portal inflammation and canalicular cholestasis, consistent with bile duct obstruction.
After placement and removal of a CBD stent, the patient was stabilized for discharge however continued to have elevated yet downtrending liver markers (102 ALT, 91 AST, 385 alk phos 11 months after initial hospitalization). Consultation with transplant hepatology confirmed post-COVID SSC-CIP; however, downtrending liver markers calls to question the need for liver transplantation at this time.
Discussion: This case provides context for SSC-CIP in post-COVID patients. Use of long term ECMO suggests that biliary ischemia was the inciting factor for development of SSC-CIP. However, despite the progressive nature of SSC-CIP described in non-COVID patients, this patient’s long-term progression has shown downtrenting AST, ALT and alk phos. Early referral to transplant hepatology might be indicated in patients whose COVID clinical course suggests SSC-CIP. Further research is indicated to determine if post-COVID SSC-CIP cholangiopathy could be self-limited.
Figure: MRCP: Multiple areas of irregular intrahepatic ductal narrowing with beading and small pockets of fluid adjacent to the ducts. No extrahepatic ductal abnormalities. Findings are likely related to cholangitis.
Amina Kureshi indicated no relevant financial relationships.
Eleazer Yousefzadeh indicated no relevant financial relationships.
Amina Kureshi, 1, Eleazer Yousefzadeh, MD2. P0059 - Is Post-COVID SSC-CIP (Secondary Sclerosing Cholangitis in Critically Ill Patients) Self-Limited?, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.