INTRODUCTION: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 virus, is a predominantly respiratory tract infection with the capacity to affect multiple organ systems. Abnormal liver tests, mainly transaminase elevations, have been reported in hospitalized patients. We describe a syndrome of cholangiopathy in patients recovering from severe COVID-19 characterized by marked elevation in serum alkaline phosphatase (ALP) accompanied by evidence of bile duct injury on imaging. METHODS: We conducted a retrospective study of COVID-19 patients admitted to our institution from March 1, 2020, to August 15, 2020, on whom the hepatology service was consulted for abnormal liver tests. Bile duct injury was identified by abnormal liver tests with serum ALP > 3x upper limit of normal and abnormal findings on magnetic resonance cholangiopacreatography. Clinical, laboratory, radiological, and histological findings were recorded in a Research Electronic Data Capture database. RESULTS: Twelve patients were identified, 11 men and 1 woman, with a mean age of 58 years. Mean time from COVID-19 diagnosis to diagnosis of cholangiopathy was 118 days. Peak median serum alanine aminotransferase was 661 U/L and peak median serum ALP was 1855 U/L. Marked elevations of erythrocyte sedimentation rate, C-reactive protein, and D-dimers were common. Magnetic resonance cholangiopacreatography findings included beading of intrahepatic ducts (11/12, 92%), bile duct wall thickening with enhancement (7/12, 58%), and peribiliary diffusion high signal (10/12, 83%). Liver biopsy in 4 patients showed acute and/or chronic large duct obstruction without clear bile duct loss. Progressive biliary tract damage has been demonstrated radiographically. Five patients were referred for consideration of liver transplantation after experiencing persistent jaundice, hepatic insufficiency, and/or recurrent bacterial cholangitis. One patient underwent successful living donor liver transplantation. DISCUSSION: Cholangiopathy is a late complication of severe COVID-19 with the potential for progressive biliary injury and liver failure. Further studies are required to understand pathogenesis, natural history, and therapeutic interventions.

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Background: Non-alcoholic fatty liver disease (NAFLD) encompasses a spectrum of conditions from simple hepatic steatosis to non-alcoholic steatohepatitis (NASH), a condition that includes fat accumulation, inflammation, and cell death. The single factor that predicts early death in patients with NASH is hepatic fibrosis. Hence, early identification and risk stratification of individuals with NASH and fibrosis is essential.Methods: A panel comprising 11 liver disease specialists was assigned sections of the manuscript to present at a consensus meeting in December 2019. The goal was to develop a care pathway for primary care providers (PCPs) to identify patients at risk for NAFLD, stratify risk, and refer those in need of specialty services. Results:We developed a simple algorithm to identify risk factors for NAFLD and recognize patients with progressive hepatic fibrosis. Patients with obesity, type 2 diabetes, abnormal liver tests, or incidental findings of hepatic steatosis should be evaluated for NAFLD, hepatic fibrosis and cardiovascular risk using family history and accepted calculators (FIB-4 and ACC/AHA). Risk stratification includes cardiovascular and hepatic complications. Patients with ≥ stage 2 fibrosis by non-invasive testing should be referred to hepatologists. We recommend lifestyle interventions and medical management of comorbidities for patients with NAFLD. Patients should be followed long-term with assessment of liver status every 6 months.Conclusions: Using this algorithm in a primary care setting may raise awareness of risk factors for NAFLD, encourage timely lifestyle interventions, promote appropriate prescribing habits, result in more effective use of specialist consultations, and improve patient outcomes.

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