Beyond the Bladder: Ketamine Cholangiopathy With Renal and Electrolyte Complications

Ketamine-induced uropathy is well recognised, but chronic ketamine use can also injure the bile ducts.This ketamine cholangiopathy is less familiar and may mimic primary sclerosing cholangitis (PSC), bile duct stones, or malignancy.We describe a 26-year-old man with many years of heavy ketamine use (about 4 g daily) who was found collapsed and needed three days of intensive care.He had cholestatic liver blood tests without jaundice: alkaline phosphatase (ALP) 1014 U/L, gamma-glutamyl transferase (GGT) 3873 U/L, and bilirubin 7 µmol/L, with normal alanine aminotransferase (ALT), albumin, and international normalised ratio (INR).Magnetic resonance cholangiopancreatography (MRCP) showed a 25 mm narrowed segment of the intrapancreatic common bile duct with upstream dilatation to 12 mm, unchanged from three months earlier, with no stones, a normal pancreas and no convincing features of PSC.Viral, autoimmune, immunoglobulin G4 (IgG4) and carbohydrate antigen 19-9 (CA 19-9) tests were negative.Ketamine cholangiopathy was considered the most likely diagnosis, and the gastroenterology team deferred endoscopic investigation in favour of a repeat MRCP at six months.He also had ketamine uropathy, with bilateral hydroureteronephrosis and a small, contracted bladder with urothelial calcification.His admission was complicated by acute kidney injury (creatinine 85 to 350 µmol/L), which improved after urinary catheterisation, recurrent hyperkalaemia and chronic hyponatraemia attributed mainly to high fluid intake.Repeated intravenous calcium gluconate for hyperkalaemia was followed by a transient, treatment-related rise in calcium.Kidney function and potassium normalised, sodium mildly improved but remained low, and he was discharged with drug and alcohol team follow-up.Clinicians should consider ketamine use in young patients with unexplained cholestasis.Ketamine cholangiopathy can mimic PSC, stones or malignancy, and coexisting uropathy and electrolyte disturbances are important clues and complications.Recognising this pattern can support an individualised approach in which invasive tests such as endoscopic retrograde cholangiopancreatography (ERCP) may be deferred, with close imaging follow-up.