TABLE 1.

A Step-wise Approach in COVID-19 Patients Suspected to Have Hepatobiliary Disease

Determine cause(s)

COVID-19 infection per se  Complication of COVID-19 or treatment   Sepsis   Hypoxic injury and/or ventilator complications   Drugs including antibiotics and experimental therapy  Pre-existing liver disease that may not have been diagnosed (HAV, HBV, HCV, HEV, MAFLD, alcohol-related liver disease, autoimmune liver disease, other) Concomitant medical problems Examples: Common bile duct obstruction (stones) Malignancy of liver or biliary tract Ascites Thrombosis (Budd-Chiari, portal vein thrombosis) Exclude nonhepatic causes of abnormal liver tests

Determine need for further evaluation and urgency of intervention

Conservative approach is the rule   No invasive procedure   Defer further imaging, use bedside ultrasound if needed  Exceptions   Findings that may determine disease outcome and if diagnosed/treated have major implications Examples: Ascitic tap: decompensated cirrhosis vs. malignancy and rule out infection Ultrasonography: common bile duct obstruction—stones vs. mass Liver biopsy: autoimmune hepatitis? Can we treat without biopsy? EGD for upper GI hemorrhage

EGD indicates esophagogastroduodenoscopy; HAV, hepatitis A virus; HBV, hepatitis B virus; HCV, hepatitis C virus; HEV, hepatitis E virus; GI, gastrointestinal; MAFLD, metabolic dysfunction-associated fatty liver disease.