key: cord-1023235-ydvw42z7
authors: Dhaliwal, Amaninder; Dhindsa, Banreet Singh; Esquivel, Rene Gomez
title: COVID Bile Duct: Biliary Cast Syndrome as a Complication of SARS-CoV-2 Infection
date: 2022-03-16
journal: J Gastrointest Surg
DOI: 10.1007/s11605-022-05297-x
sha: 3b2372d166c4b2eebb400e4d838963a0beb19710
doc_id: 1023235
cord_uid: ydvw42z7

nan

A 42-year-old female with a history of orthotopic heart transplant (2014) on chronic immunosuppression, chronic kidney disease, and diabetes mellitus presented with complaints of nausea, vomiting, and pruritus. Six weeks prior, she had a month-long admission for acute respiratory distress syndrome secondary to COVID-19 infection. Treatment during her COVID-19 admission included convalescent plasma and tocilizumab. Liver enzymes during that admission peaked at AST 196, ALT 236, ALP 344, and total bilirubin 1.3; however, they all returned to normal by discharge. These abnormalities were attributed to severe sepsis from COVID-19 infection. Computed tomography (CT) of the abdomen during that admission revealed normal hepatobiliary anatomy with no internal or external biliary dilatation. On this admission, laboratory workup was significant for AST 94, ALT 83, ALP 1003, and total bilirubin of 4.6. Magnetic resonance cholangiopancreatography (MRCP) revealed mild intrahepatic biliary ductal dilation with subtle central biliary enhancement concerning for cholangitis along with hypodense material in extrahepatic biliary system likely representing transiting gallbladder sludge. Endoscopic retrograde cholangiopancreatography (ERCP) with liberal sphincterotomy revealed filling defects secondary to multiple large biliary casts, the largest measuring approximately 7 cm in length ( Figs. 1 and 2) . The biliary tree was swept using a 12-15-mm balloon with resultant resolution of extrahepatic filling defects on final cholangiogram. There were few filling defects noted in the intrahepatic ducts at the end of the procedure. LFTs trended down, and she was eventually discharged home in stable condition. She had two more subsequent ERCPs with balloon extraction of multiple small biliary casts from the intrahepatic ducts.

Biliary cast syndrome is a well-recognized complication of orthotopic liver transplantation; however, to the best of our knowledge, this is the first case report of biliary cast syndrome secondary to severe COVID-19 infection. Our patient developed biliary cast syndrome due to the binding of the virus to ACE2 receptors found in the hepatic cholangiocytes resulting in an inflammatory response leading to liver abnormalities and cholestasis. Abnormalities in AST, ALT, and bilirubin are well documented in COVID-19-infected patients; however, severe elevations in ALP as was seen in our patient are rare. [1] [2] [3] As the pathogenesis of COVID-19 becomes better understood, cholestasis with possible biliary cast syndrome should be considered as a potential complication of the COVID-19 virus in a patient with abnormal LFTs, especially after a severe infection. All listed authors participated meaningfully in the study, and they have seen and approved the final manuscript.

Competing Interests None.

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