Systematic Reviews
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 7, 2023; 29(1): 200-220
Published online Jan 7, 2023. doi: 10.3748/wjg.v29.i1.200
Liver pathology in COVID-19 related death and leading role of autopsy in the pandemic
Martina Zanon, Margherita Neri, Stefano Pizzolitto, Davide Radaelli, Monica Concato, Michela Peruch, Stefano D'Errico
Martina Zanon, Davide Radaelli, Monica Concato, Michela Peruch, Stefano D'Errico, Department of Medical Surgical and Health Sciences, University of Trieste, Trieste 34149, Italy
Margherita Neri, Department of Medical Sciences, University of Ferrara, Ferrara 44121, Italy
Stefano Pizzolitto, Department of Pathology, Santa Maria della Misericordia University Hospital, Udine 33100, Italy
Author contributions: Zanon M and D'Errico S contributed to the writing and conceptualization; Neri M and Pizzolitto S contributed to the formal analysis and investigation; Radaelli D and Concato M contributed to the data curation; Peruch M contributed to the supervision.
Conflict-of-interest statement: The authors declare no conflict of interest for this article.
PRISMA 2009 Checklist statement: The review followed the PRISMA 2009 checklist statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Stefano D'Errico, PhD, Assistant Professor, Department of Medical Surgical and Health Sciences, University of Trieste, Strada di Fiume, Trieste 34149, Italy.
Received: September 13, 2022
Peer-review started: September 13, 2022
First decision: October 30, 2022
Revised: November 14, 2022
Accepted: December 21, 2022
Article in press: December 21, 2022
Published online: January 7, 2023

Information on liver involvement in patients with coronavirus disease 2019 is currently fragmented.


To highlight the pathological changes found during the autopsy of severe acute respiratory syndrome coronavirus 2 positive patients.


A systematic literature search on PubMed was carried out until June 21, 2022.


A literature review reveals that pre-existing liver disease and elevation of liver enzyme in these patients are not common; liver enzyme elevations tend to be seen in those in critical conditions. Despite the poor expression of viral receptors in the liver, it seems that the virus is able to infect this organ and therefore cause liver damage. Unfortunately, to date, the search for the virus inside the liver is not frequent (16% of the cases) and only a small number show the presence of the virus. In most of the autopsy cases, macroscopic assessment is lacking, while microscopic evaluation of livers has revealed the frequent presence of congestion (42.7%) and steatosis (41.6%). Less frequent is the finding of hepatic inflammation or necrosis (19%) and portal inflammation (18%). The presence of microthrombi, frequently found in the lungs, is infrequent in the liver, with only 12% of cases presenting thrombotic formations within the vascular tree.


To date, the greatest problem in interpreting these modifications remains the association of the damage with the direct action of the virus, rather than with the inflammation or alterations induced by hypoxia and hypovolemia in patients undergoing oxygen therapy and decompensated patients.

Keywords: Liver, COVID-19, Autopsy, Immunohistochemistry, In situ hybridization, Immunofluorescence

Core Tip: A literature review, about liver pathology in coronavirus disease 2019 (COVID-19) patients, demonstrates the presence of liver damage, which is represented mainly by congestion, steatosis, hepatic inflammation and necrosis, and portal inflammation. The problem to date is whether the damage is COVID-19 related (meaning from direct virus damage/inflammatory related/systemic pathology related) or drug induced. However, this demonstration involves the need to be careful during drug treatment in patients with altered liver enzyme values to prevent further clinical worsening.