Deranged liver enzymes are common finding in COVID-19 patients. Usually, it is in the form of altered aminotransferases picked up during routine investigations. The cause of the liver injury is not clearly established, but most likely, it seems multifactorial, with a cytokine storm and immune dysregulation possibly playing a role so it could be hypoxia, hypotension, multiple drugs, direct viral effect, and ICU-related infections.

There are data indicate that 2–11% of patients with COVID-19 had liver comorbidities and 14–53% cases reported abnormal levels of alanine aminotransferase and aspartate aminotransferase (AST) during disease progression. Patients with severe COVID-19 seem to have higher rates of liver dysfunction(in a study in The Lancet by Huang and colleagues,^5).

Furthermore, in another study,⁸ liver injury is more prevalent in severe cases than in mild cases of COVID-19. AST abnormal (22·2%), ALT abnormal (21·3%)(1.Guan W-J,Ni Z-Y, Hu Yet al.Clinical characteristics of 2019 novel coronavirus infection in China.N Engl J Med. 2020; (published online Feb 28.)

The liver injury may manifest as jaundice, hypochondric pain, fatigue, low grade fever, but the raised transferases abnormally is one of the most common issue. TCM therapies have been used to help liver disorders effectively in clinic. According to the manifestations of the liver injured post Covid-19, it can be referred to Jaundice and hypochondric pain in TCM. Shang Han Lun says: Exterior cold exists simultaneously with interior deposited heat which surely leads jaundice. The Golden Chamber on Jaundice says: The Jaundice is due to dampness. Dr Ye Gui in his book, Case Records as a Guide to Clinical Practice on Jaundice says: Treat stomach for Yang Jaundice. Treat spleen for Yin jaundice. Since then, many effective TCM formula and acupuncture therapies have been used for improving liver trasaminases.

What is the etiology, pathogenesis and therapy?

The turbid dampness of Covid-19 lingers inside long term and turns to heat, dampness and heat mixes and invades liver and gall bladder, resulting incorporation between liver and gall bladder, the bile is forced out abnormally and the liver function is injured by the damp heat, manifested as raised liver transaminases and Yang Jaundice. Or the dampness of Covid-19 turns to cold, damp cold accumulates spleen, liver energy is blocked, resulting in raised liver transaminases. The bile is blocked, and the bile moves out abnormally, resulting in Jaundice.

• Damp heat in the liver and gall bladder: Damp heat of Covid-19 not only invades the lung, also affects the liver and gall bladder, the liver function injured as following.

Manifestations: Liver AST and ALT raise rapidly or yellow eyes, hypochondrial fullness and pain, low grade fever, poor appetite, red tongue with yellow greasy coating, wiry pulse.

Treatment strategy: soothe liver and clear heat, resolve dampness and decrease transaminases.

Formula: Yin Chen Hao Tang.

For both dampness and heat severe, Long Dan Xie Gang Tang may be used. For significant abnormal liver transaminases, add Wu Wei Zi, Gan Huang Cao, Chui Peng Cao. For dampness, add Fu Ling, Zhu Ling. For nausea, vomiting, add Zhu Ru, Chen Pi. For heat and thick yellow greasy coating, add Huang Bai, Huang Qin.

Acupuncture points: GB34, Liv13, SP9, UB19, REN12.

For nausea, vomiting, add PC6, UB20. For heat, add LI11 and ST44.

• Liver Qi stagnation: Resentment, frustration with Covid-19 can cause stagnation of liver Qi, which disorders the soothing function of liver and leads raised liver transaminases. After a long time, the stagnation of liver qi may give rise to liver stasis or to liver heat.

Manifestations:

Treatment strategy: Regulate liver Qi, harmonize the liver function.

Formula: Xiao Yao San

For Qi stagnation turning to heat, add Mu Dan Pi, Zhi Zi. For Qi stagnation with blood stasis, add Dan Shen, Yu Jin.

Acupuncture points: Liv3, LI4, Ren6, SP6.

For heat, add DU14, LI11. For blood stasis, add SP10, UB17.

• Spleen deficiency and dampness accumulation: The Yang consumption of spleen post Covid-19 or the exterior damp cold of Covid-19 lingers inside, which may lead to the formation of damp cold in the spleen and damage the liver and ball bladder functions, or bile is blocked resulting in jaundice.

Manifestations: Chronic abnormal liver transaminases, dull jaundice and hypochondrial pain, fatigue, poor appetite, loose face, tasteless of mouth, pale tongue with white and greasy coating, sluggish pulse.

Treatment strategy: Strengthen spleen and stomach, warm interior and resolve dampness, decrease transaminases.

Formula: Yin Chen Zhu Fu Tang.

For transaminases, may add Shan Zha, Mu Gua,Wu Wei Zi, Gan Huang Cao. For fullness of abdomen, add Hou Po, Cang Zhu. For tasteless, add Huo Xiang, Zi Su Ye.

Acupuncture points: ST36, SP6, REN4(Moxa), LIV13.

For fullness of abdomen, add ST25, REN12. For tasteless, add SP4, Ear tongue.

• Stasis of liver blood: The liver Qi stagnation, Damp heat or cold of Covid-19 after a long time, all of them may give rise to blood stasis resulting in injured liver function.

Manifestations: Abnormal liver transaminases that is difficult to be helped, stabbing and fixed hypochondrial pain, feeling of a mass of palpation, purple tongue with choppy or wiry.

Treatment strategy: Soothe the liver, move Qi and blood, improve the liver transaminases.

Formula: Chai Hu Su Gan San.

For significant blood stasis, add Dan Shen, Jiang Huang. For significant high of liver transaminases, add Hu Zhang, Gan Huang Cao. For hypochondrial pain, add Yu Jin, Tao Ren.

Acupuncture points: LIV3, LIV5, SP21, UB17.

For blood stasis, add SP10, LIV King. For hypochondrial pain, add LIV13.

Other therapies:

Ear points: Gall Bladder, Liver, Spleen, Stomach.

Patent herbs:

Gan Su Jiao Nang(Recovering Liver Capsules): it is used for abnormal liver transaminases due to damp heat in liver and gall bladder. 2 capsules per time, 3 times per day.

Fu Fang Yi Gan Pian(Complex Strengthen Liver Pills): it is used for abnormal liver transaminases. 4 pills per time, 3 times per day.

Chui Pen Cao Granules(Herba Sedi Powder): it is used for abnormal liver transaminases. 10g per time, 3 times per day.

-Dr. Bai Song Zhong