Cholangioscopy in a Post-Covid-19 Cholangiopathy Patient

Abstract

Arq Gastroenterol • 2022. v. 59 nº 2 abr/jun • 321 Main textAcute liver chemistry elevations occur frequently in patients with coronavirus disease 2019 (COVID-19) (1) . An unusual condition of secondary sclerosing cholangitis in critically ill patients has been recognized as a novel entity after COVID-19 infection (2) and recently named post-COVID-19 cholangiopathy. It is characterized by marked cholestasis associated with ongoing jaundice that persists long after pulmonary and renal recovery (3) . This E-VIDEO describes a SpyGlass ® cholangioscopy in a post-Covid-19 cholangiopathy patient.A 65-year-old men with diabetes, hypertension, and chronic lymphocytic leukemia, under hematologic follow-up, was hospitalized for COVID-19 associated acute respiratory distress syndrome 10 months prior, and underwent mechanical ventilation for 13 days under Fentanyl, Midazolam, and Ketamine sedation. 10 days after hospital admission, he presented progressive increase of canalicular enzymes without transaminases or ultrasound abnormalities. At day 33 he was discharged, and his laboratory bloody tests included alkaline phosphatase of 807, gamma glutamyl transferase of 1831, and total bilirubin of 1.3. 1 month later he presented jaundice and progressive bilirubin increase, being started ursodeoxycholic acid without improvement. Endoscopic retrograde cholangiopancreatography (ERCP) revealed rarefaction of intrahepatic bile ducts (FIGURE 1), and removal of biliary casts (FIGURE 2). Patient did not show improvement of the condition, and cholangioscopy was indicated to endoscopically evaluate the bile duct and verify its viability. The procedure demonstrated scar retraction areas (FIGURE 3), as well as dark endothelial shedding, removed with Spybite®. In the confluence of the hepatic ducts, edema and diffuse ischemic pattern (FIGURE 4) was noted with retractions that cause important stenosis extending to intrahepatic segments (FIGURE 5).

Post-COVID-19 Cholangiopathy: A Systematic Review

“…We identified 30 cases of patients with PCC that matched our inclusion criteria. [ 4 , 9 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ] (Table- 1). Most cases described were from the United States of America [ 4 , 9 , 13 , 14 , 15 ].…”

“…A total of 106 cases were identified by our literature search. We extracted information from 28 articles ( Taslble- 1 ) [ 4 , 9 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ] . We collected data on patients’ demographics, symptom onset, liver associated values including initial values and peak values, diagnostic modalities, pathology findings, modes of treatments and overall disease course.…”

“…The most frequent laboratory definition used for a diagnosis of COVID-19 cholangiopathy included: COVID-19-induced cholestasis was defined as a rise in alkaline phosphatase (ALP) by ≥ 1.5 times the upper limit of normal (ULN) with serum bilirubin (≥2 ULN); gamma glutamyl transferase (GGT) (≥3 ULN); absence of active sepsis; and exclusion of other underlying causes of chronic liver disease (8-13). The most common features of severe pulmonary COVID-19 were: respiratory rate >30/minute; dyspnea and/or SpO2 < 90% on room air; and need for mechanical ventilation related to COVID-19 illness; and detectable COVID-19 by polymerase chain reaction (PCR) [ 4 , 9 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ].…”

“…Twenty-nine of the thirty patients in our cohort underwent magnetic retrograde cholangiography (MRCP) [ 4 , 9 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ]. The results of the MRCP examinations are shown in Table 5 .…”

“…The results of the MRCP examinations are shown in Table 5 . The most common finding reported in 23 patients was intrahepatic bile ducts beading with multiple short segmental strictures and intervening dilatation [ 4 , 9 , 13 , 14 , 15 , 17 , 18 , 19 , 20 , 21 ]. Bile duct thickening and hyper enhancement was reported in 14 patients and peribiliary diffusion high signal reported in 13 patients [ 13 , 14 , 15 , 16 ].…”