Endoscopic Features of Post-COVID Cholangiopathy Defined


New data shed light on endoscopic features and the “indispensable” role of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and management of post–COVID-19 cholangiopathy.


  • To more precisely define the endoscopic features of post–COVID-19 cholangiopathy,researchers analyzed clinical data and endoscopic findings observed in 141 ERCP procedures for 46 patients who developed new-onset cholangiopathy during SARS-CoV-2 infection. None had a history of preexisting biliary tract disease.

  • The diagnosis of post–COVID-19 cholangiopathy was established by a characteristic clinical course with progressive cholestasis in conjunction with bile duct lesions in ERCP.

  • All patients were followed from the time of diagnosis until liver transplantation or death.


  • Post–COVID-19 cholangiopathy can be classified as a variant of secondary sclerosing cholangitis in critically ill patients. This form of cholangiopathy was more destructive than stricturing in nature and caused irreversible damage to the bile ducts.

  • Diagnostic criteria are destruction of intrahepatic bile ducts in a centripetal direction, no extrahepatic involvement, vanishing bile ducts, biliary cast syndrome, and multifocal peribiliary abscesses.

  • Post-COVID cholangiopathy is not a late complication of intensive care treatment; rather, bile duct damage is an early event in the course of COVID-19.

  • Prognosis is dismal, with a 1-year liver transplant–free survival rate of 44%. In particular, patients with peribiliary liver abscesses or destruction of the central bile ducts tended to have a poor prognosis.

  • Interventional endoscopy with cast removal had a positive effect on cholestasis parameters (gamma-glutamyl transpeptidase, alkaline phosphatase, and bilirubin), with 58.1% of all individual values decreasing.


“Gastrointestinal endoscopy plays an important role in management of post-COVID-19 cholangiopathy. ERCP is not only of great diagnostic and prognostic value, but also has therapeutic value and therefore remains indispensable,” the authors write.


The study, with first author Silke Leonhardt, MD, of Charité-Universitätsmedizin Berlin in Germany, was published online October 16 in the American Journal of Gastroenterology.


The study authors report no limitations.


The study had no third-party funding. The authors have declared no relevant conflicts of interest.

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