Introduction Although COVID-19 is transmitted via respiratory droplets, there are multiple gastrointestinal and hepatic manifestations of the disease, including abnormal liver-associated enzymes. However, there are not many published articles on the pathological findings in the liver of COVID-19 patients. Methods We collected the clinical data from 17 autopsy cases of COVID-19 patients including age, sex, BMI, liver function test (ALT, AST, ALP, direct bilirubin and total bilirubin), D-dimer and anticoagulation treatment. We examined histopathologic findings in postmortem hepatic tissue, immunohistochemical (IHC) staining with antibody against COVID spike protein, CD68 and CD61, and electron microscopy. We counted the number of megakaryocytes in liver sections from these COVID-19 positive cases. Results Abnormal liver-associated enzymes were observed in 12/17 cases of COVID-19 infection. With the exception of three cases that had not been tested for D-dimer, all 14 patients’ D-dimer levels were increased, including the cases that received varied doses of anticoagulation treatment. Microscopically, the major findings were widespread platelet-fibrin microthrombi, steatosis, histiocytic hyperplasia in the portal tract, mild lobular inflammation, ischemic-type hepatic necrosis and zone 3 hemorrhage. Rare megakaryocytes were found in sinusoids. COVID IHC demonstrates positive staining of the histiocytes in the portal tract. Under electron microscopy, histiocyte proliferation is present in the portal tract containing lipid droplets, lysosomes, dilated ribosomal endoplasmic reticulum (RER), micro-vesicular bodies and coronavirus. Conclusions The characteristic findings in COVID-19 patients’ liver include numerous amounts of platelet-fibrin microthrombi as well as various degrees of steatosis and histiocytic hyperplasia in the portal tract. Possible mechanisms are also discussed.

INTRODUCTION: Intussusception is common in children, but rare in adults accounting for 5-16% of all cases of intussusception. Giant pseudopolyps are polyps that measure more than 1.5 cm in diameter. These can function as lead points for intussusception in patients with inflammatory bowel disease (IBD). We present here an unusual case of intussusception due to a giant pseudopolyp in an adult patient with ulcerative colitis. There are only a limited number of case reports that describe this occurrence. CASE DESCRIPTION/METHODS: A 20-year-old man with a history of ulcerative colitis in remission on 5-ASA and 6-Mercaptupurine was found on surveillance colonoscopy to have a large inflammatory pseudopolyp resulting in partial obstruction. He was asymptomatic and physical examination was unremarkable. CT Abdomen/Pelvis showed transverse colon intussusception (Figure 1). He underwent a repeat colonoscopy with plan for endoscopic submucosal dissection of the large polyp. A 15 × 15 cm, frond-like/villous, broad based pseudopolyp without a stalk was seen in the proximal transverse colon (Figure 2a). Due to the large size of the polyp and inability to visualize the dissection plane, endoscopic submucosal dissection could not be performed. Debulking was achieved using piecemeal mucosal resection with a snare. A 15 × 15 cm area was resected and retrieved (Figure 2b). Histopathology showed fragmented pseudopolyp with ulceration, extensive granulation tissue and regenerative epithelial changes (Figure 3). He did well post procedure and was discharged home. He was advised to undergo colectomy but he remains undecided. He will undergo surveillance colonoscopy in 6 months. DISCUSSION: In adults, intussusception is a rare finding and most cases are due to colonic malignancy. Colocolonic intussusception secondary to giant pseudopolyps is an extremely rare occurrence in IBD patients. Presentation of these patients can vary from asymptomatic, abdominal pain, rectal bleeding, obstruction or intussusception. Although giant pseudopolyps do not have a malignancy risk, there has been one reported case of occult malignancy in a giant pseudopolyp. In addition, IBD patients at baseline are at an increased risk for malignancy. Asymptomatic patients can be managed medically. Successful endoscopic therapy with polypectomy has been reported in a few cases of giant pseudopolyps. Complications such as obstruction or intussusception require surgery. However, all of these patients will require frequent endoscopic surveillance.