Endosonographic and ERCP findings in COVID-19 critical illness cholangiopathy.

A 56-year-old female developed deep jaundice months after struggling with critical illness, needing hemodialysis, and tracheostomy, due to COVID-19. Lab tests included alkaline phosphatase 1574U/L, total bilirubin 11mg/dL, ALT 88U/L, AST 101U/L. Baseline liver tests were normal before illness. ANA, IgG4 level, and viral hepatitides were negative. The patient was unable to tolerate MRCP due to dyspnea, and CT-contrast could not be done due to renal disease. EUS and ERCP were pursued. EUS showed a left hepatic duct stricture and heterogenous, non-shadowing cylindric objects in the main bile duct. ERCP confirmed LHD stricture with upstream dilation of the left ducts, and obliteration of right intrahepatics with secondary sclerosing changes. Brushings and biopsies of the stricture ruled out malignancy. Casts were swept. The left lobe was stented with a 10 Fr 20 cm plastic stent improving bilirubin level to a baseline of 3 mg/dl. Critical illness cholangiopathy results in secondary sclerosing cholangitis. In this case, it is unclear whether the patient suffered these changes as a direct cause of COVID-19 or as a result of critical illness cholangiopathy. The overall prognosis is guarded given its progressive nature and likely need for liver transplantation.