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
Research background

Hepatic histologic manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are far to be completely investigated. Many authors demonstrated the presence of angiotensin converting enzyme 2 receptor in the liver as well as transmembrane serine protease 2.

Research motivation

Liver injury was demonstrated in 14%-53% of cases of patients with SARS-CoV-2 infection. In the first wave of the pandemic few autopsies were performed and only few authors can provide a wide casistic. Authors started to study the histologic manifestations of coronavirus disease 2019 (COVID-19) in the lungs, heart, and liver, too.

Research objectives

The objectives of the study were to summarize the biochemical and histological changes in the liver and to promote the leading role of autopsy in the pandemic.

Research methods

Authors provide a systematic review focusing on autopsy studies of COVID-19 deaths and in particular on liver pathology.

Research results

Forty-six articles corresponding to the inclusion criteria were included, with only 994 autopsy cases of COVID-19 patients. Congestion and steatosis were the main histopathological findings, followed by hepatic necrosis, hepatic and portal inflammation, and fibrosis. The most frequent cause of death was respiratory failure, pulmonary thrombosis, and sepsis. Acute liver failure was indicated as the cause of death in two cases.

Research conclusions

The review of the literature highlighted the presence of a great discrepancy in the autopsy protocols, with only half of the autopsies performed as complete (full autopsies), while the other half as partial. Macroscopic and microscopic evaluation of the liver was not always performed or described. Despite the presence of hepatic injury, the presence of SARS-CoV-2 in the liver has been sought infrequently (16% of the cases).

Research perspectives

Much more effort needs to be addressed to completely investigate liver toxicity from COVID-19. Autopsies had a leading role during the pandemic and were important to understand the physiopathology of SARS-CoV-2 infection and should be always considered to improve scientific research.