Ketamine-Induced Cholangiopathy With Concomitant Hemorrhagic Cystitis: An Emerging and Underrecognized Cause of Cholestasis

Ketamine-induced cholangiopathy (KIC) is a rare but increasingly recognized manifestation of chronic ketamine toxicity, often accompanied by urinary tract injury such as hemorrhagic cystitis. We report the case of a 55-year-old female with recurrent hemorrhagic cystitis and a long-standing history of intermittent recreational ketamine use who presented with asymptomatic cholestatic liver enzyme abnormalities. Hepatobiliary ultrasound revealed hepatic steatosis without ductal dilatation, and magnetic resonance cholangiopancreatography demonstrated multifocal biliary stricturing with a beaded appearance of the intrahepatic bile ducts. Serological testing for autoimmune and infectious etiologies was negative. Cystoscopy revealed inflammatory bladder changes, and histopathology confirmed ketamine-induced hemorrhagic cystitis. Following cessation of ketamine use, the patient demonstrated biochemical improvement. This case emphasizes the multisystem toxic potential of ketamine, highlighting the importance of recognizing KIC with concomitant hemorrhagic cystitis as an emerging cause of cholestasis and urinary tract injury.