Sonographic findings in coronavirus disease-19 associated liver damage

Abstract

Purpose This study was conducted to evaluate the role of liver sonography in patients with coronavirus disease 2019 (COVID-19) and elevated liver enzymes. Materials and methods In this retrospective study, patients tested positive for SARS-CoV-2 in our emergency ward between January 01 and April 24, 2020 and elevated liver enzymes were included (Cohort 1). Additionally, the local radiology information system was screened for sonographies in COVID-19 patients at the intensive care unit in the same period (Cohort 2). Liver sonographies and histologic specimen were reviewed and suspicious findings recorded. Medical records were reviewed for clinical data. Ultrasound findings and clinical data were correlated with severity of liver enzyme elevation. Results Cohort 1: 126 patients were evaluated, of which 47 (37.3%) had elevated liver enzymes. Severity of liver enzyme elevation was associated with death (p<0.001). 8 patients (6.3%) had suspicious ultrasound findings, including signs of acute hepatitis (n = 5, e.g. thickening of gall bladder wall, hepatomegaly, decreased echogenicity of liver parenchyma) and vascular complications (n = 4). Cohort 2: 39 patients were evaluated, of which 14 are also included in Cohort 1. 19 patients (48.7%) had suspicious ultrasound findings, of which 13 patients had signs of acute hepatitis and 6 had vascular complications. Pathology was performed in 6 patients. Predominant findings were severe cholestasis and macrophage activation. Conclusion For most hospitalized COVID-19 patients, elevated liver enzymes cause little concern as they are only mild to moderate. However, in severely ill patients bedside sonography is a powerful tool to reveal different patterns of vascular, cholestatic or inflammatory complications in the liver, which are associated with high mortality. In addition, macrophage activation as histopathologic correlate for a hyperinflammatory syndrome seems to be a frequent complication in COVID-19.

COVID‐19 pathophysiology and ultrasound imaging: A multiorgan review

“…Furthermore, a study by Abdelmohsen et al showed that US diagnosis in COVID‐19 patients of hepatomegaly and biliary disease was found in 56% and 41% of imaging exams, respectively 156 . US is further used for the primary analysis of hepatobiliary alterations and, therefore, may be used in cases of damage associated with cholangiocytes and cholestasis 148 …”

“…147 The main findings in the liver US in COVID-19 patients include hepatomegaly, changes in the liver echogenicity (suggesting hepatic infarction or hepatic steatosis), heterogeneity of hepatic parenchyma, signs of necrosis, increased gallbladder thickness and drastic reduction in the Doppler signal imaging in the hepatic arteries and portal vein. 148 All such US alterations may be induced either by direct or indirect SARS-CoV-2 infection. 148 The increase in cases of portal vein thrombosis (PVT) is an alarming complication observed in COVID-19 cases, which may trigger intestinal infarction and ischemia.…”

“… 156 US is further used for the primary analysis of hepatobiliary alterations and, therefore, may be used in cases of damage associated with cholangiocytes and cholestasis. 148 …”

“…148 All such US alterations may be induced either by direct or indirect SARS-CoV-2 infection. 148 The increase in cases of portal vein thrombosis (PVT) is an alarming complication observed in COVID-19 cases, which may trigger intestinal infarction and ischemia. 149 Even with prophylactic measures in the ICU, the frequency of thrombotic complications in critically ill patients is around 30%.…”

Impact of COVID-19 on liver

“…Sonographic findings of ALI, including signs of acute hepatitis ( e.g. , thickening of the gall bladder wall, hepatomegaly, and decreased echogenicity of the liver parenchyma) and vascular complications, appeared in 48.7% of COVID-19 ICU patients and 37.3% of COVID-19 patients[ 42 ]. In COVID-19 patients, ground-glass opacity was the most common finding (56.4%) on chest computed tomography (CT) on admission[ 43 ].…”