Deluge of Liver Disease Due to COVID-19?

Two articles in a recent issue of Hepatology describe both direct and indirect effects of COVID-19 on the liver.

The first study with 2273 patients (MM Phipps et al Hepatology 2020; 72: 807-817. Full Text: Acute Liver Injury in COVID‐19: Prevalence and Association with Clinical Outcomes in a Large U.S. Cohort), with retrospective data, describes how most cases of COVID-19 are mild. Severe cases of liver disease are generally a marker for elevated inflammatory markers and severe systemic disease. Key findings:

  • 45% had mild (ALT <2 x ULN), 21% moderate (ALT 2-5 x ULN), and 6.4% severe liver injury (SLI) (ALT >5 x ULN).
  • Patients with SLI had a more severe clinical course, including higher rates of intensive care unit admission (69%), intubation (65%), renal replacement therapy (RRT; 33%), and mortality (42%).
  • In multivariable analysis, peak ALT was significantly associated with death or discharge to hospice (OR, 1.14; P = 0.044), controlling for age, body mass index, diabetes, hypertension, intubation, and RRT

Going into this new year, the more concerning effects of COVID-19 pandemic for the liver is likely to be the increase is severe chronic liver disease related to alcohol (and perhaps fatty liver disease too). The second article (BL Da et al. Hepatology 2020; 72: 1102-1108. Coronavirus Disease 2019 Hangover: A Rising Tide of Alcohol Use Disorder and Alcohol‐Associated Liver Disease) discusses the expectation of increased liver disease due to alcohol use disorder (AUD) and alcohol-associated liver disease (ALD). Key points:

  • In China, reports indicate a “>2-fold increase in harmful drinking after COVID-19, an effect likely repeated in the United States where an estimated 12.7% of the population has AUD and ALD is responsible for the highest hospitalization cost burden among all chronic liver diseases (CLDs).”
  • Increased alcohol use is likely to worsen other chronic liver diseases in addition to ALD
  • In addition, all of these effects are compounded by avoidance of health care facilities and delays in care

My take: COVID-19 infections have direct effects on the liver. However, the increased use of alcohol as well as weight gain are likely to be more important in terms of liver-related morbidity and mortality.

More Often Than Not Esophagitis in Children with Esophageal Atresia is NOT due to Reflux

A long time ago in a galaxy far far away, I was taught that children with esophageal atresia would have reflux for life due to dysmotility following repair. Thus, these children presumably should remain on acid blockers indefinitely. It turns out that this was fiction (just like Star Wars).

R Tambucci et al J Pediatrics 2021; 228: 155-165. Full text: Evaluation of Gastroesophageal Reflux Disease 1 Year after Esophageal Atresia Repair: Paradigms Lost from a Single Snapshot?

In this retrospective study with 48 children, the authors had the following key points:

  • Microscopic esophagitis was found in 33 (69%)
  • Pathological esophageal acid exposure on MII-pH was detected in 12 (25%)
  • The presence of long-gap esophageal atresia was associated with abnormal MII-pH.

The authors conclude that “histological esophagitis is highly prevalent at 1 year after esophageal atresia repair, but our results do not support a definitive causative role of acid-induced GERD. Instead, they support the hypothesis that chronic stasis in the dysmotile esophagus might lead to histological changes.”

My take: Along with endoscopy, pH probe testing can be helpful in selecting which children with esophageal atresia should continue with PPI therapy.

Related blog posts:

Oley: Check it out

Recently, I received a post from Oley Foundation (Linda May) asking me whether I was going to its convention.  While I am not, I did want to share that link:
The conference is in lovely Redono Beach, CA, right on the beach. We have miles of running paths, beautiful beaches, on site tennis courts, and swimming pool . To quote other MDs, “the Oley Annual conference is the most important clinical conference I attend all year…”

Also, Oley website is a good link for patients with enteral tubes, ostomies, and central lines.

Many questions and how-to advice available.  For example, look at this link if interested in advice about swimming with central line, or enteral tube: