Staff Anesthesiologist Cleveland Clinic Cleveland, Ohio, United States
Introduction: Post-COVID-19 cholangiopathy (PCC) is an extra-pulmonary complication of COVID-19, causing liver damage via a cholestatic pattern. PCC is prevalent in ICU-admitted COVID-19 patients and is marked by severe cholestasis, jaundice, and ascites persisting after renal and pulmonary recovery. The pathophysiology of PCC remains unclear. Hypotheses include ischemia and cholangiocyte necrosis, direct viral cholangiocyte injury, or host inflammatory response. Currently, there is no consensus on therapeutic management. Pharmacologic treatments, including ursodeoxycholic acid, plasma exchange, and ERCP interventions, have shown limited efficacy. However, orthotopic liver transplantation (OLT) has demonstrated promising results. We report a case of PCC successfully treated with OLT.
Description: A 73-year-old male with hypertension, CAD, OSA, and post-COVID-19 cholangiopathy (MELD 32) presented with fatigue, jaundice, ascites, shortness of breath and anorexia for several months post-COVID-19. Despite multiple pharmacologic interventions, his condition deteriorated, necessitating liver transplant as a last resort. The intraoperative course was uneventful, and he was admitted to the surgical ICU. Within 24 hours, he was weaned off ventilatory and vasopressor support, remaining alert and stable. His ICU stay included complications of acute kidney injury (AKI), left leg deep vein thrombosis, and ileus, managed effectively. A liver ultrasound one-week post-OLT confirmed patent vasculature. Total bilirubin levels decreased from 25-32 mg/dL preoperatively to around 10 mg/dL two weeks post-LT, indicating significant liver function improvement. He was discharged home 2.5 weeks after surgery with ongoing follow-up.
Discussion: Post-COVID-19 cholangiopathy (PCC) is an emerging and challenging condition with uncertain pathophysiology and no standardized treatment. Our patient showed severe cholestasis and liver dysfunction, which significantly improved after orthotopic liver transplantation (OLT), suggesting OLT as a viable and potentially curative option for advanced PCC. Individual case reports like ours can heighten clinical suspicion for PCC, facilitate earlier diagnosis, and underscore the importance of considering OLT, especially for patients unresponsive to conventional medical treatment modalities.
