Introduction

COVID-19, as a systemic disease, critically affects the liver and biliary system. Secondary sclerosing cholangitis (SSC) is an increasing complication in critically ill patients. After severe COVID-19 infection, the occurrence of bile duct changes resembling the picture of SSC has been increasingly observed. The early prognosis of COVID-19-associated SSC has not been adequately studied.

Aims & Methods

The aim of this study is to investigate the effects of COVID-19 on the liver in relation to previous hepatic disease, as well as to identify early prognostic markers for the course of disease in patients and the development of any complications. 261 patients treated in intensive care units of the University Hospital Regensburg and suffering from COVID-19 were analyzed in different groups. The classification was based on the presence and type of previous hepatic disease. Laboratory and clinical parameters collected during hospitalization included values at the time of admission and maximum values that developed during hospitalization. These were evaluated concerning mortality rates and the development of COVID-19-associated SSC in the different patient groups.

Results

Patients with pre-existing chronic liver disease had a hazard ratio for death of 2.045 (p=0.0446) compared to patients without chronic liver disease. The hazard ratio for death was higher for patients with pre-existing chronic liver disease than for patients with malignant disease (HR=1.986, p=0.0135) or dialysis requirement on ICU admission (HR=1.732, p=0.034). In all groups, mortality was also significantly correlated with an increase in liver enzymes during hospitalization. High bilirubin (p=0.002) or INR (p=0.018) levels on admission also correlated with increased mortality, independent of pre-existing hepatic disease. Among the entire cohort, the cause of death was associated with COVID-19 in 90.8%. In addition, the risk of developing COVID-19-associated SSC increased with the duration of ECMO therapy and correlated significantly (p=0.004) with high AP levels on admission.

Conclusion

This study demonstrates the potent effects of COVID-19 on the liver and biliary system and potential complications in patients with and without pre-existing chronic liver disease. Bilirubin and INR could serve as predictive factors for mortality. AP could be considered an early predictor for the development of COVID-19-associated SSC in patients with COVID-19. In the future, this will provide crucial clues for an optimized treatment strategy, including ventilation and sedation.

Introduction

MACE is a new, non-invasive technology which approaches the diagnostic sensitivity of OGD in gastric focal lesion detection in patients with dyspepsia. [Li et al., CGH 2016] This study compared the two in the detection of focal and diffuse lesions in patients referred for the investigation of anaemia.

Aims & Methods

MACE was performed within one week before OGD using the AnX Robotica magnet system and Navicam capsule (single camera capsule, frame rate 6/sec: Wuhan, China). Following a fast, simethicone and gastric distension using 0.5-1L water, patients swallowed the capsule semi-recumbent on the left lateral side before lying supine to allow approximation of the magnet to the chest. The examination protocol included a sequence of magnet movements and patient position changes. Inspection of an anatomical location was considered complete if sufficient to exclude any significant pathology. Endoscopists performing OGD were blinded to the MACE outcome and all findings were recorded from a pre-identified diagnostic list. Data was analysed using SPSS.

Results

45 of 81 (55.5%; median age 63 (IQR 45.5- 72), 60% male) patients had pathology identified by MACE, OGD or both. Complete views were obtained by MACE in the oesophagus (72.4%), proximal stomach (93.8%), distal stomach (93.8%) and duodenum(79.6%, p<0.001) and mean examination time was 22 minutes. Findings were concordant in 17 (37.8%: gastric erosions (n=6), ulcers (n=5), oesophagitis (n=2), eroded polyps (n=2) and gastric antral vascular ectasia (n=2)). MACE alone identified pathology in 24 (53.3%: gastric erosions (n=17), angioectasia (n=4), ulcers (n=2, oesophageal and duodenal), eroded polyp (n=1) and both angioectasia and erosions (n=1). OGD identified a distal body ulcer (n=1), small (n=1) and large (n=1) oesophageal varices and oesophageal ulcers (n=1) missed by MACE and in one patient MACE identified only an oesophageal ulcer and OGD only a duodenal ulcer, each missing the pathology detected by the other. Diagnostic yield was higher for MACE than OGD (P<0.001).

Conclusion

The improved diagnostic yield of MACE compared to OGD is accounted for mainly by minor mucosal abnormalities which could, nonetheless, contribute to occult bleeding and anaemia. Although speculative this could be because of better tolerance of MACE and a longer examination time. An increased frame capture rate, with or without a second camera, is needed to improve oesophageal visualisation.

Disclosure

I herwith declare that the magnetic capsules for the study were provided by Ankon

Clinical Case Summary

A 78-year-old female with personal history of ischemic cardiomyopathy and atrial fibrillation was referred to a tertiary center due to iron deficiency anemia without clinical evidence of gastrointestinal bleeding. The patient required periodic erythrocyte transfusion and intravenous iron treatment. An upper and lower endoscopy was performed, yielding unremarkable findings.
In this context, the patient underwent capsule endoscopy which revealed an ileal polypoid ulcerated lesion close to a Meckel diverticulum. Subsequently, a double balloon retrograde enteroscopy was performed, with identification of a Meckel diverticulum without ulcers nor active bleeding. Furthermore, a 15-millimeter diameter polypoid lesion was also seen and removed using a diathermic snare after submucosa injection, clip and loop application. The histopathological report confirmed a pyogenic granuloma, also known as lobular capillary hemangioma. After lesion removal the patient experienced anemia resolution.
Pyogenic granuloma is a rare benign proliferation of capillary vessels, most commonly affecting the skin and oral mucosa, characterized by friable bright red papules. Nevertheless, gastrointestinal involvement can also occur. The high vascularization associated with these lesions justifies the presence of iron deficiency anemia due to gastrointestinal losses. This case highlights a rare small bowel pyogenic granuloma. Despite its association with iron deficiency anemia, the occurrence of a pyogenic granuloma in this context, particularly in the enteric mucosa, is uncommon. Nevertheless, recent studies suggest that this clinical entity may be underdiagnosed due to improper identification of inflammatory or hyperplastic polyps. Capsule endoscopy and device assisted enteroscopy were crucial in localizing and ensuring proper therapeutic management of this lesion, thereby solving the iron deficiency anemia.

References

1. Capsule endoscopy images with identification of the Meckel diverticulum and pyogenic granuloma
2. Device-assisted enteroscopy images with identification of the Meckel diverticulum and pyogenic granuloma
3. Histopathological sample of pyogenic granuloma