Post-COVID-19 cholangiopathy
Letter to the Editor

Post-COVID-19 cholangiopathy

Ana Maria Graciolli1, Bruna Raasch De Bortoli1, Caroline Maslonek1,2, Eveline Maciel Corrêa Gremelmier2, Carlos Frederico Henrich3^, Karina Salgado4,5^, Raul Angelo Balbinot6,7^, Silvana Sartori Balbinot6,7^, Jonathan Soldera4,6,8^

1School of Medicine, Universidade de Caxias do Sul, Caxias do Sul, Brazil; 2Intensive Care, Hospital Virvi Ramos, Caxias do Sul, Brazil; 3Radiology, Clínica Vero/Dellaudo, Caxias do Sul, Brazil; 4Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil; 5ICAP Pathology, Caxias do Sul, Brazil; 6Clinical Gastroenterology, School of Medicine, Universidade de Caxias do Sul, Caxias do Sul, Brazil; 7Gastroenterology, Universidade de São Paulo, São Paulo, Brazil; 8Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil

^ORCID: Carlos Frederico Heinrich, 0000-0002-8434-8498; Karina Salgado, 0000-0003-2867-3808; Raul Angelo Balbinot, 0000-0003-4705-0702; Silvana Sartori Balbinot, 0000-0002-5026-1028; Jonathan Soldera, 0000-0001-6055-4783.

Correspondence to: Prof. Jonathan Soldera, MD, MSc. Associate Professor of Clinical Gastroenterology, School of Medicine, Universidade de Caxias do Sul, Ver Mário Pezzi Av., 699/801, Caxias do Sul, RS, CEP 95084-180, Brazil; Master’s in Medicine, Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil; Doctoral Student, Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil. Email:

Received: 23 December 2022; Accepted: 17 April 2023; Published online: 04 May 2023.

doi: 10.21037/dmr-22-83

In our clinical experience with the Gamma variant in Brazil, we have come across many cases of this novel clinical entity. There was one case in 2020 that has left a mark in our practice, published in the beginning of 2021 in Portuguese (1). A 63-year-old male previously healthy patient developed a severe case of coronavirus disease 2019 (COVID-19) respiratory disease, needing prolonged mechanical ventilation and high-dose vasopressor drugs. He was admitted to the hospital on April 27, 2020. He was treated with multiple antibiotics during his stay, the last ones were an association of imipenem, polymyxin B and amikacin for a New Delhi metallo-beta-lactamase (NDM) Pseudomonas aeruginosa infective endocarditis. He underwent an endoscopic retrograde cholangiopancreatography (ERCP), which found a choledochal cast, composed of microlithiasis in the pathology report. He also underwent a percutaneous transhepatic cholangiography, which showed sclerosing cholangitis associated with intrahepatic lithiasis. He was discharged on September 25, 2020 with liver transplantation referral. After a couple of weeks of the hospital discharge, he was readmitted with a new severe sepsis, and the family opted for palliative care, and died not long afterwards. We believe this might be the first case reported of this entity, with extensive workup, including ERCP and percutaneous transhepatic cholangiography (PTHC), showing the presence of casts and lithiasis in the intra and extra-hepatic biliary tract, which makes this case unique. As based in the article by Roth et al. (2), we have put together a table summarizing our data (Table 1).

Table 1

Summary of the reported case

Clinical characteristics of patients with severe cholangiopathy during recovery from COVID-19 Reported case data
Patient demographics
   Age (years) 63
   Sex Male
   Ethnicity/race Caucasian
   Hypertension No
   Diabetes mellitus No
   Other pre-existing comorbidities No
Clinical characteristics of COVID-19 infection
   Hospitalizations Day 1–151
   Acute rehabilitation No
   Subacute rehabilitation No
   Mechanical ventilation and tracheostomy Yes
   Venovenous extracorporeal membrane oxygenation No
   Vasopressor support Yes
   Biventricular systolic heart failure No
   Acute kidney injury Yes → hemodialysis
   Renal replacement therapy Yes
   Secondary infections Pseudomonas aeruginosa endocarditis
   Other notable complications Infection by Candida albicans
   Hydroxychloroquine No
   Azithromycin Yes
   Ivermectin No
   Corticosteroids Yes
   Tocilizumab No
   Anakinra No
   Convalescent plasma Yes
   Remdesivir No
   Antibiotics Azithromycin, Ampicillin + Sulbactam, Imipenem, Levofloxacin, Meropenem, Piperacillin, Polymyxin B, Trimethoprim, Sulfamethoxazole and Vancomycin
Liver chemistries (serum) on admission (day 1)
   Antifungal medications Fluconazole
   Alkaline phosphatase (U/L) 202
   Aspartate aminotransferase (U/L) 111
   Alanine aminotransferase (U/L) 39
   Total bilirubin (mg/dL) 25.20
Peak liver chemistries (serum)
   Alkaline phosphatase (U/L) 936 (day 46)
   Aspartate aminotransferase (U/L) 378 (day 46)
   Alanine aminotransferase (U/L) 690 (day 46)
   Total bilirubin (mg/dL) 31.9 (day 96)
Last available liver chemistries (serum)
   Days after initial admission Day 173
   Alkaline phosphatase (U/L) 238
   Aspartate aminotransferase (U/L) 105
   Alanine aminotransferase (U/L) 78
   Total bilirubin (mg/dL) 30.9
Hepatobiliary imaging findings
   Cirrhotic morphology No
   Hepatomegaly No
   Extrahepatic bile duct dilatation Yes
   Intrahepatic bile ducts Dilatation, stenosis and intrahepatic lithiasis in a transhepatic percutaneous cholangiography
   Endoscopic retrograde cholangiography (days after initial admission) Choledochal casts, suggestive of microlithiasis in the pathology report
Histologic parameters
   Liver biopsy (days after initial admission) Suggestive of drug-induced cholangitis
Portal tract findings
   Bile duct paucity (% of portal tracts with interlobular bile ducts) Not identified
   Ductular reaction Mild
   Cholangiocyte swelling (bile ducts, ductules) Severe
   Cholangiocyte regenerative change (bile ducts) No
   Portal tract inflammation (lymphoplasmacytic, with scattered neutrophils) Mild
   Hepatic arteries Without changes
   Portal veins Without changes
   Terminal hepatic veins Without changes
   Parenchyma Without changes
   Immunohistochemistry Not done
   Fibrosis No

COVID-19, coronavirus disease 2019.

COVID-19 infection might cause liver injury, which is generally mild and transient. Although, in more severe cases, the patients might develop an entity entitled “post-COVID-19 cholangiopathy”. In 2021, two articles published in the American Journal of Gastroenterology discussed in total 15 cases of this disease (2,3). The case described had a cast removed in ERCP and we found one case similar to ours published in 2022 (4). It has been suggested that the diagnosis and management of this disease might demand an ERCP, especially if a dilated choledocus is identified in imaging studies (5,6). An actual cause is yet to be determined, but it is believed that it might be secondary to infection by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus or by drug-induced liver injury, since these patients sometimes use ketamine and carbapenems for long periods of time (7). Since we know so little of this entity, diagnosis and treatment for this condition are continuously revised as per available information. Symptoms, clinical signs, laboratorial manifestations, and imaging findings of the post-COVID-19 cholangiopathy do not differ from other etiological types. An adequate treatment is yet to be determined, but it seems that liver transplantation might have good results (8-11).

In conclusion, as the COVID-19 pandemic is now transforming into an endemic, we will have to manage the long-term consequences of this infection. Liver transplantation programs will require more data in this pathology, since it seems as of right now the only adequate readily available therapy in the long term (12).


Funding: None.


Provenance and Peer Review: This article was commissioned by the editorial office, Digestive Medicine Research. The article has undergone external peer review.

Peer Review File: Available at

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The family of the deceased patient has verbally agreed in the reporting of this case. All clinical procedures described in this article were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). The family of the deceased patient has verbally agreed in the reporting of this article.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See:


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doi: 10.21037/dmr-22-83
Cite this article as: Graciolli AM, De Bortoli BR, Maslonek C, Gremelmier EMC, Henrich CF, Salgado K, Balbinot RA, Balbinot SS, Soldera J. Post-COVID-19 cholangiopathy. Dig Med Res 2023;6:29.

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