P1908 - Post COVID-19 Biliary Cast Syndrome: A Novel Disease

Pratik Patel, MD¹, Nyingi Kemmer, MD, MSc, MPH², Saurabh Agrawal, MD^2
1University of South Florida, Titusville, FL; ²Tampa General Medical Group, Tampa, FL

Introduction: Liver injury as a result of COVID-19 infection has become well documented in the literature as our understanding of the infectious process improves. A less common complication of COVID-19 is the development of biliary tract disease similar to what is seen in secondary sclerosing cholangitis in the critically ill patient (SSC-CIP). An even more rare complication is the formation of biliary casts as a result of COVID-19. We present a small case series of two patients who developed biliary casts after severe COVID-19 infection.

Case Description/Methods: Our first patient is a 43 year old female with a history of orthotopic heart transplant secondary to ischemic cardiomyopathy who presented with respiratory distress. She developed cholestasis and underwent liver biopsy which revealed cholestasis with bile ductular reaction and stage 2 fibrosis. ERCP revealed a large CBD cast. Post extraction cholangiogram revealed intra and extra-hepatic biliary strictures, consistent with post COVID Cholangiopathy.

Our second patient is a 42 year old male with no significant medical history who was admitted for respiratory distress. He underwent liver biopsy which revealed cholestasis. EUS revealed no cholelithiasis or biliary ductal dilation. ERCP revealed biliary casts in the left hepatic ducts. There was no evidence of SSC-CIP on post contrast cholangiogram.

Discussion: The impact of COVID-19 on the liver has become an important topic in Hepatology as its association with liver damage is now well researched. Biliary tract abnormalities are not commonly encountered post COVID-19. COVID-19 virus binding to receptors of angiotensin converting enzyme 2 (ACE2) and the increase in interleukin-6 levels during acute infection have been implicated as potential causes for liver enzyme derangements. Post COVID cholangiopathy is a novel term used for patients that develop SSC-CIP. While there are more reports of COVID cholangiopathy, to our knowledge there is only reported case of biliary casting secondary to COVID-19. Our series describes two patients that underwent lengthy hospitalizations for severe COVID-19 and subsequently developed biliary casts. One of the two patients also developed SSC-CIP. Post COVID biliary casting is a new condition that should be considered for patients who present with cholestasis and have a history of severe COVID-19. ERCP with extraction of cast is the immediate treatment, however orthotopic liver transplantation for post-COVID cholangiopathy has also recently been described in literature.




Disclosures:


Pratik Patel, MD¹, Nyingi Kemmer, MD, MSc, MPH², Saurabh Agrawal, MD². P1908 - Post COVID-19 Biliary Cast Syndrome: A Novel Disease, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.