The coronavirus pandemic has affected every one of us. In these difficult times, patients find it difficult to visit hospitals and clinics for routine follow-up visits. People suffering from liver diseases need to take certain special precautions during the pandemic. Discussed below are the effects of the novel coronavirus on the liver and general guidelines that patients with chronic liver diseases are advised to follow during the pandemic.
The Effects of SARS-nCoV-2 on the Liver
COVID19: The novel coronavirus can have diverse effects on the liver. Cytopathic action of the virus, immune damage from the provoked immune response, liver injury from drugs used to treat patients with severe symptoms and ischemic liver injury resulting from low blood pressure are few of the mechanisms that cause liver injury. The commonest laboratory finding iselevated serum liver enzymes (AST and ALT levels) seen in14% to 53% of cases. The serum bilirubin value can be normal to modestly elevated early in the disease. The liver injury may increase depending on the severity of the disease. Rare cases of severe acute hepatitis have also been reported. However, in the majority of cases, liver injury in mild and transient, rarely requiring any specific treatment.
For Stable Outpatients with Liver Disease and/or Hepatocellular Carcinoma
All patients suffering from chronic liver disease have an associated immune dysfunction, and thus have a higher risk of contracting the infection. Patients with non-alcoholic fatty liver disease related cirrhosis have a higher risk of severe disease, probably due to the underlying obesity and associated diabetes mellitus. Further, older patients also have a higher risk of severe disease. Following are simple steps that patients with a stable liver disease should follow while visiting their doctor.
• Any person with a new onset severe liver disease should be evaluated at the earliest.
• It is advisable to visit with a prior appointment; one must call the reception prior to visit to estimate the wait-time.
• Patients are advised to avoid unnecessary travel.
• Kindly ensure proper documentation prior to travel.
• Request the receptionist for an early room-in.
• It is desirable to avoid crowded waiting areas.
• One must maintain appropriate social distance in the outpatient area.
• One must also limit the number of family members/friends who accompany.
• Patients with stable liver disease should try and limit outpatient visits if possible till the pandemic abates.
• It is worthwhile to use phone or video consultations to replace in-person visits.
Suggestions regarding medications for patients with chronic liver disease
• Patients taking treatment for Hepatitis B and C should continue their antiviral treatment.
• Patients suffering from autoimmune liver disease must continue steroids/immunosuppressant drugs.
• It is desirable to procure adequate refill of medications for atleast 3 months.
• Patients are advised to adhere to prophylaxis for spontaneous bacterial peritonitis and hepatic encephalopathy to avoid unnecessary admissions.
• For patients with established cirrhosis, surveillance for hepatocellular carcinoma should be continued, however an arbitrary delay of 2-3 months is acceptable.
• All elective/non-urgent procedures (e.g., endoscopy, liver biopsy, Fibroscan) can be avoided for few months.
• Vaccination for Streptococcus pneumoniae and Influenza is suggested to be taken on time.
For patients with Decompensated Cirrhosis, Liver Transplant Evaluations, and patients on the Liver Transplant Waiting List
• It is desirable to limit the number of hospital/clinic visits.
• COVID19 should be suspected in any new onset acute decompensation of liver disease.
• There will be an expected reduction in the number of donated organs – this may impact patients on the transplant wait-list.
• Evaluation for liver transplantation is advisable only for patients with liver cancer, high MELD scores and severe liver disease till the pandemic subsides.
• Diagnostic laboratory and radiology visits must be undertaken with precautions.
• If admitted, in-hospital family/visitor access should bereduced/prohibited.
• All recipients/donors should be tested for COVID19 prior to the surgery.
Post liver transplantation care
• There is no requirement to reduce immunosuppressivemedications and their doses unless one contractsCOVID19.
• It is recommended to follow preventive measures: frequent hand washing, cleaning frequently touched surfaces, staying away from large crowds, staying away from individuals who are ill and wearing masks.
• Any unnecessary travel should be avoided.
• Telemedicine consultation should be utilized for routine follow-up.
DNB (Gastroenterology), MRCP-SCE (Gastroenterology)
Fellow in Clinical and Transplant Hepatology
Consultant Gastroenterologist, Hepatologist and GI Endoscopist
Apollo Hospitals, Navi Mumbai