Introduction

On 31^st December 2019, “Wuhan Municipal Health Commission”, China recorded a cluster of patients who are suffering from pneumonia in Hubei Province. Eventually SARSCoV2 is identified (Zhu, Zhang, & Wang, 2020). COVID-19 was declared as a pandemic disease on 11^th March 2020, by the “World Health Organization” (WHO) and requested respective Governments, health care officials, scientific teams and all denizens should organize ourselves to slow-down the spreading of COVID-19, take remedies, restrict the negative effects and search more accurate cure.

In 2012 MARS “Middle East Respiratory Syndrome” was also seen which is caused by a coronavirus. According to “International Taxonomy Group”, this pandemic COVID-19 has been identified as SARSCoV2 “Severe Acute Respiratory Distress Syndrome” (Gorbalenya, Baker, & Baric, 2020).

Recent virology researches done by Zhou and colleagues have presented up to 80% similarity between SARS-CoV (in 2003 the virus got spread to 26 countries where more than 8000 population got affected) and the recent novel coronavirus.

Almost 60% of patients who suffered from SARS epidemic 2003 had developed various degrees of liver damages (Gorbalenya et al., 2020). As it COVID19 virus resembles the SARS phylogenitically; this is believed that novel coronavirus can also cause hepatobilliary damage. With the uses of antiviral and quinoline the chances of risk of liver injury may be there.

Transmission

The primary route of SARS CoV-2 is a contact of mucous with respiratory droplets. It evolved as a zoonotic infection; howsoever, these viruses transmit in a flash from one person to another and become a pandemic. The novel coronavirus is resilient and may remain potent for up to 14 days, depending on the viral carrier and the immunity of the affected person (Zhu et al., 2019). Also, ACE2, the receptor protein of both SARS-CoV and 2019-nCoV, is abundantly present in humans in the epithelia of the lung and small intestine, and coronaviruses can infect the upper respiratory and gastrointestinal tract (Chen, 2020). In a community, the transmission potential of infection is based on its basic reproduction rate which is usually indicated as “Disease Transmission Ratio” (R0). It determines the number of secondary cases occurred from an index case in a susceptible population. In SARS CoV 2003 R0 was reduced to 0.4 and COVID-19 is 2.2. The evidence collected from various sources indicates that COVID-19 extensively spreads in confined settings like hospitals, prisons, cruise ships and religious places. Pandemic outbreaks in restricted settings require investigation of the changes in the active reproduction number occurring as a consequence of interventional strategies such as quarantine and self-isolation of the travellers and crew members on board (McDonald & Kubes, 2016).

Clinical Feature

The clinical feature of COVID19 as similar to that of viral pneumonia and having most common symptoms as

• Feverish Condition

• Cough

• Sore throat

• Impaired taste and smell

Some of the less common symptoms such as

• Aches and pains

• Tiredness

• Skin rashes

• Discoloration of fingers or toes

• Diarrhoea

• Because of the predominant distribution of the main viral entry receptor, such as angiotensin-converting enzyme2 (ACE2), COVID-19 causes many systemic disorder, having relatable involvement of vital organs such as lungs, heart, kidneys, liver additionally determines alterations of the circulating white blood cells and the immune system (Huang et al., 2020)^.

Hepatic Dysfunction In Covid-19

SARSCoV2 associated hepatic dysfunction is determined as any liver injury occurred during the onset of the disease, progression and treatment of COVID-19 patients with or without having a previous history of liver abnormalities. The gross incidence of increased serum level in indoor patients infected with novel coronavirus primarily elevated Aspartate Aminotransferase (AST) and Alanine transminase (ALT) and with little increased bilirubin level (i.e. from 14.0% to 53.0%). Elevated levels of Liver enzymes are seen more frequently in men and most of the serious cases (Gorbalenya et al., 2020).

Albumin act as a marker: low albumin stands for a severe infectious condition with poor prognosis. Till now, 2-11% of patients with COVID19 had underlying hepatic dysfunction.

Viral Effect On Liver

The liver receives both the portal and systemic circulation: hence it is involved in most systematic infections. Its a vital organ for host defence and immunity (Huang et al., 2020). Some of the viruses exhibit a direct cytotoxic effect on hepatocytes and cholangiocytes; however, in maximum cases, the pathogenesis based on the multiple factors.

Hepatocellular necrosis, fatty degeneration and cellular infiltration are the usual pathological outcome of a liver biopsy specimen of SARS patients. Some of the current autopsy-records of hepatic tissue of COVID-19 patients show mild infectious nature in the lobular and portal area (Zhu et al., 2019).

However, these patterns of histological damages have multi etiological factors. But they can also be seen during infectious condition or “Drug-Induced Liver Injury” (DILI).

Mechanism Of Liver Injury

• Immune mediated injuries as an outcome of the severe inflammatory responses following SARSCoV2 infection

It shows increased the inflammation bio-markers that includes C-Reactive protein (CRP), Lactate Dehdrogenase, D-dimer, Interleukin-6, Interleukin-2 and serum ferritin (Cui, Tian, & Huang, 2020).

2. Direct cyto-toxicity as a result of active viral replication in liver cells

Novel coronavirus attaches to target cells through ACE2. As it is expressed more in the liver and mainly on biliary epithelial cells, the hepatic cell is a potential target for direct inflammation.

3. Anoxia

Hypoxic hepatitis is seen frequently in several cases.

4. Drug-induced liver injury (DILI)

Initially, WHO recommends the clinicians to use antiviral drugs such as remdesivir, hydroquinilones, chloroquine, flavipiravir. These are being potentially hepatotoxic in some patients (Huang et al., 2020).

5. Pre-existing liver disease reactivation

A person having pre-existing chronic hepatic disorder, are more susceptible to hepatic injuries from COVID-19. Agents such as tocilizumab and baricitinib may cause HBV re-activation and often leads to hepatic degeneration (Sahu & Naqvi, 2020). Various mechanisms are indicated as below [Figure 1].

Clinical Implication

1. Continuous tracking of liver biochemical parameters should be done in every of the COVID-19 patients.

2. Serologic testing for Hepatitis B and C should be done

3. Assessment of elevated hepatic biochemistries should be noted.

4. All approaches towards the safety of the medicines used for the cure of COVID-19 patients with liver injuries are empirical.

5. Severe liver injury is rare, but the efficiency of the liver is compromised.

Management Of Liver Diseases

The various process of managing liver diseases are [Figure 2].

Prevention

Currently, we are lacking medicinal aids to manage the pandemic. The tools to combat COVID-19 are mainly quarantine and social distancing (Srivastava, Shrivastava, Chhabra, Naqvi, & Sahu, 2020). Other method includes

• Use soap hand-wash or an alcohol-based hand rub to clean the hands.

• Wearing a face mask.

• Avoid gatherings.

• Maintain a physical distance of 2 meters

• Avoid touching eyes, nose or mouth frequently.

• Stay home as much as possible.

• If you have a high temperature, cough and difficulty breathing, ask for medical attention.

• Govt. need to modify their strategies to contain the spreading of COVID19, testing methods and treatment protocols in accordance to the WHO Guidelines.

Conclusion

COVID-19 caused by novel coronavirus "SARS-CoV-2” is a pandemic condition. The fatality rate is nearly 3% but higher in patients with older age and co-morbidities. Symptoms are more relatable to pneumonia, but hepatobilliary dysfunction may be seen in some of the serious cases and may associate with fatal results. Prolong studies with follow-ups are necessary for assessment of the intensity of hepatic damages done due to COVID-19. The effects of COVID-19 related drugs and Novel Corona Virus on underlying chronic liver disorder needs a detailed evaluation; so that the hepato-toxicity can be reduced.

Funding Support

The authors declare that they have no funding support for this study.

Conflict of Interest

The authors declare that they have no conflict of interest for this study.