Ketamine cholangiopathy: clinical features and liver biopsy findings

To reveal clinical, imaging and pathological features of ketamine cholangiopathy.

Eight cases, who had a history of long-term ketamine use, abnormal liver function tests and histological or radiological evidence of cholangiopathy, were retrospectively reviewed. Cases consisted of six men and two women with a median age of 36 years. Ketamine was clinically prescribed in one case for pain control or used recreationally in the remaining seven for 3-24 years (median = 12 years) until the diagnosis of cholangiopathy. Six cases had a prior diagnosis of ketamine-induced cystitis ('ketamine bladder') or urinary symptoms at the time of referral. No patient had inflammatory bowel disease, and autoantibodies were negative in all but one case. Common cholangiographic abnormalities included diffuse irregular narrowing of the intrahepatic bile ducts (n = 5) and mild dilatation of the extrahepatic bile ducts with a smooth contour (n = 5). Liver biopsies showed features of chronic cholangiopathy. Portal and lobular inflammation was mild or absent, and degrees of fibrosis were also relatively mild (Ludwig's stages 1-2). Periductal concentric fibrosis or fibrous duct obliteration was observed in four cases. Abstinence from ketamine was successful in three cases, and one showed normalisation of liver blood tests.

Ketamine cholangiopathy mimics primary sclerosing cholangitis (PSC) biochemically, radiologically and histologically, and it seems to be less inflammatory and less progressive compared to PSC. The association with cystitis, the lack of inflammatory bowel disease and mild extrahepatic duct dilatation without irregularity are potential diagnostic clues.