Secondary sclerosing cholangitis as cause of persistent jaundice in patients with severe COVID‐19

Bütikofer, Simon; Lenggenhager, Daniela; Garcia, Pedro David Wendel; Maggio, Ewerton Marques; Haberecker, Martina; Reiner, Cäcilia S.; Brüllmann, Gregor; Bühler, Karl Philipp; Gubler, Christoph; Müllhaupt, Beat; Jüngst, Christoph; Morell, Bernhard

BACKGROUND & AIMS: Little is known about cholestasis including its most severe variant secondary sclerosing cholangitis (SSC), in critically ill patients with coronavirus disease 19 (COVID‐19). In this study we analyzed the occurrence of cholestatic liver injury and SSC, including clinical, serological, radiological and histopathological findings. METHODS: We conducted a retrospective single‐center analysis of all consecutive patients admitted to the intensive care unit (ICU) due to severe COVID‐19 at the University Hospital Zurich to describe cholestatic injury in these patients. The findings were compared to a retrospective cohort of patients with severe influenza A RESULTS: 34 patients with severe COVID‐19 admitted to the ICU were included. 14 patients (41%) had no cholestasis (group 0), 11 patients (32%, group 1) developed mild and 9 patients (27%, group 2) severe cholestasis. Patients in group 2 had a more complicated disease course indicated by significantly longer ICU stay (median 51 days IQR 25‐86.5) than the other groups (group 0 median 9.5 days IQR 3.8‐18.3 p=0.001 and group 1 median 16 days IQR 8‐30 p< 0.05 respectively). Four patients in group 2 developed SSC compared to none in the influenza A cohort. The available histopathological findings suggest an ischemic damage to the perihilar bile ducts. CONCLUSIONS: The development of SSC represents an important complication of critically ill COVID‐19 patients and needs to be considered in the diagnostic work up in prolonged cholestasis. The occurrence of SSC is of interest in the ongoing pandemic since it is associated with considerable morbidity and mortality.