COVID-19-Induced Bile Duct Casts and Cholangitis: A Case Report

Coronavirus disease 2019 (COVID-19) infection can lead to various complications involving all of the major organ systems. Gastrointestinal manifestations such as nausea, vomiting, and diarrhea are commonly associated with this condition. Biliary complications from COVID-19 constitute an area of active research. In this report, we present a case of secondary sclerosing cholangitis in a critically ill patient (SSC-CIP) associated with COVID-19. A 57-year-old male with a past medical history of hypertension and diabetes presented to the hospital with signs of sepsis. He had abdominal pain, fever, and elevated liver enzymes without an elevated lipase. Abdominal ultrasound and CT scan showed a dilated common bile duct (CBD) with a distal CBD stone. He had experienced a prolonged course of severe critical illness related to COVID-19 prior to this episode, with respiratory failure requiring mechanical ventilation, thromboembolic complications, and he had also required tracheostomy and gastrostomy tube. The patient was diagnosed with cholangitis and was appropriately treated with antibiotics and fluid resuscitation. An endoscopic retrograde cholangiopancreatography (ERCP) was performed. During ERCP, the biliary cast was removed and a bile duct stent was placed. After the procedure, he showed significant improvement and was discharged on an appropriate course of antibiotics. Outpatient ERCP was eventually done to remove the stent and further bile duct casts were removed. The patient was referred for outpatient cholecystectomy. Critical illness due to COVID-19 can result in SSC-CIP. This can be further complicated by bile duct casts, liver fibrosis, and cirrhosis.