P0023 - The Role of ERCP in Post COVID-19 Cholangiopathy: A Systematic Review of Published Case Reports

Sunday, October 22, 2023

3:30 PM – 7:00 PM PT

Location: Exhibit Hall

Has Audio

Presenting Author(s)

OO

Olufemi E. Osikoya, MD

Medical City Arlington
Arlington, Texas

Gregory Brennan, MD¹, Olufemi E. Osikoya, MD²
¹Texas Digestive Disease Consultants, Mansfield, TX; ²Medical City Arlington, Arlington, TX

Introduction: Post COVID-19 cholangiopathy (CC) is a rare complication of COVID-19 infection. It is characterized by abnormal elevation of serum alkaline phosphatase, with evidence of bile duct injury (via imaging or biopsy) in the absence of other causes. Not much is known regarding the role of ERCP in post COVID-19 cholangiopathy. We sought to better understand the findings, interventions and outcomes in patients with CC undergoing ERCP.

Methods: We searched Pubmed, Scopus and Embase from December 2019 to present. Search words included "post-Covid-19 cholangiopathy," and “ERCP.” Data on patient characteristics, COVID-19 infection, imaging, ERCP fluoroscopic findings, ERCP interventions, post ERCP complications, and outcomes were collected.

Results: We identified 11 case reports of patients diagnosed with CC who underwent ERCP, including nine men and two women. The average age was 50 years. Most patients had severe COVID-19 infection requiring mechanical ventilation. The average peak laboratories were alkaline phosphatase 1601, total bilirubin 11.8, and ALT 223. The most common findings on ERCP were biliary tree strictures (64%), biliary stones (55%), casts (36%) and sludge (36%). The most common intervention performed during the ERCPs were stone extraction (55%), sphincterotomy (27%), and stent placement (9%). Following ERCP, two of the 11 patients were given ursodiol with subsequently improved LFTs. None of the cases reported post ERCP pancreatitis. Two patients ultimately underwent liver transplantation.

Discussion: In patients with CC, ERCP appears to be a safe and effective treatment. Reported indications for ERCP are similar to non-COVID 19 related cases, such as biliary obstruction, abnormal imaging, concern for biliary strictures and stones. The most common findings during ERCP in CC are strictures, stones, and biliary casts. Finding common bile duct stones does not rule out CC. Biliary casts seem to more common in CC patients than in the general population. Interventions are common in CC ERCPs. The most common intervention performed was stone or cast extraction. Although the diagnosis would be expected to be established prior to ERCP, CC may be a unique entity were ERCP is diagnostic. ERCP for CC appears to be safe with no reports of post ERCP pancreatitis. This study is limited by the small number of cases included. ERCP can be considered in CC patient with findings that would warrant therapeutic intervention such as, biliary stones, casts, or strictures.

Author/ year	Age	Gender	Nature of COVID infection	Presentation	Imaging finding	ERCP findings: fluoroscopy	ERCP findings	Sphincterotomy	Biliary stent placed?	Post ERCP pancreatitis? Adverse events?	Medical Treatment (ursodiol) or other
Patel et al 2021	43	F	Mechanical ventilation	Developed cholestasis; liver biopsy stage 2 fibrosis	N/A	Large CBD cast	intra/extra hep strictures	No	No	No	No
Patel et al. 2022	42	M	Mechanical ventilation, Hemodialysis	Liver biopsy: cholestasis	EUS normal	Cast in left hepatic duct	Cast extraction	No	No	No	No
Francisco et al. 2021	47	M	Mechanical ventilation	Cholestasis	US: fatty liver and gallstones no GB wall thick or dilation, CT non con: no liver nodules or dilation	Diffuse intrahepatic biliary strictures	Pigment stone removed	Yes	No	No	Liver transplant
Saleem et al. 2022	73	M	Mechanical ventilation	Cholestasis	MRCP: multiple intrahepatic strictures with beading	Biliary case &intrahepatic strictures	Biliary cast removed along with smaller stones and sludge	No	No	No	No
Saleem et al. 2023	66	M	Mechanical ventilation	Cholestasis	Abd US: intrahepatic dilation	Diffuse intrahepatic strictures, multiple CBD filling defects.	Biliary tree swept w/ large stones and cast removed	No	No	No	No
Lee et al. 2021	64	M	Mechanical ventilation	Cholestasis	CT: CBD dilation	Ductopenia with subtle ductal beading	CBD stone extraction and 8.5fr biliary stent placed	No	Yes	No	Liver Transplant (day 259)
Kobeszko et al. 2021	59	M	ICU admission	Persistent T bili of 21; liver biopsy: extensive cholestatic changes	MRCP: strictures, beading	Intrahepatic strictures	No	No	No	No	Ursodiol
Ancha et al. 2022	45	F	Mechanical ventilation ECMO	Abnormal LFT liver biopsy: minimal portal hepatitis.	MRCP: biliary dilation and intrahepatic strictures	Diffuse rarefaction of intrahepatic branches	No	No	No	No	Ursodiol
Durazo etal. 2021	49	M	Mechanical ventilation Hemodialysis	Elevated LFTs. Liver biopsy: mechanical bile duct obstruction	MRCP: mild intrahepatic biliary ductal dilatation with multifocal strictures	Diffuse intrahepatic biliary strictures	Sphincterotomy; small pigment stone retrieved	Yes	No	No	Liver transplant (day 108)
Roth et al. 2021	38	M	Mechanical ventilation ECMO Hemodialysis	Jaundice Cholestasis	Liver US normal. MRCP Day 81: MRCP showed beading w/ multiple short segmental strictures and intervening dilation). MRCP day 158: same	Biliary sludge	Sludge extracted	No	No	No	No
Roth et al. 2022	25	M	ICU admission	Jaundice Cholestasis Liver biopsy: Profound cholangiopathy	MRCP: diffuse biliary ductal dilation	Filling defects	Stone and sludge extraction	Yes	No	No	No

Table: Post COVID-19 cholangiopathy and ERCP cases.

Disclosures:

Gregory Brennan indicated no relevant financial relationships.

Olufemi Osikoya indicated no relevant financial relationships.

Gregory Brennan, MD¹, Olufemi E. Osikoya, MD². P0023 - The Role of ERCP in Post COVID-19 Cholangiopathy: A Systematic Review of Published Case Reports, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.