ACRT Journal

Introduction

Ketamine is an N-methyl-D-aspartate (NMDA) receptor antagonist originally developed as an anesthetic agent. In recent years, its use has shifted toward recreational purposes, particularly among young adults, for its dissociative and hallucinogenic effects [1]. Alongside the rise in recreational use, a growing number of serious medical complications have been reported [2]. Urinary tract complications associated with chronic ketamine use, commonly known as “ketamine bladder syndrome,” are well documented. They include urinary frequency, pelvic pain, dysuria,

hematuria, and urinary incontinence. In severe cases, progression to bladder fibrosis, hydronephrosis, and renal failure can occur [3,4]. Hepatobiliary complications, although less frequently reported, are increasingly recognized. These include cholestasis, biliary duct dilatation, elevated liver enzymes, and, in some cases, bile duct fibrosis [5,6]. The underlying pathophysiological mechanisms remain incompletely understood but are thought to involve direct toxicity of ketamine metabolites on the biliary and urinary epithelia, microvascular injury, and chronic inflammatory processes [7]. We report the case of a 24- year-old female chronic ketamine user who presented with severe urinary and hepatobiliary complications. This case underscores the importance for clinicians to consider such complications in young patients with unexplained abdominal pain and highlights the need for early and appropriate management.

Case Report

A 24-year-old woman presented to the emergency department in January 2025, transported by ambulance for acute right flank pain. While on her way to a job interview, she experienced a vasovagal episode triggered by the intensity of the pain, which she rated as 8/10 on the Visual Analog Scale (VAS). The pain was colicky and non-radiating. The patient denied nausea, vomiting, gastrointestinal disturbances, urinary symptoms, or fever. Her medical history was notable for chronic ketamine use via inhalation, at a rate of 1 g per day for five years. She had made several attempts at detoxification in psychiatric settings. The first hospitalization in 2022 was voluntarily discontinued after one week. The second, in 2023, and the third, in January 2025, were also prematurely terminated against medical advice. Despite these attempts, the patient continued to use ketamine. Additionally, she reported longstanding urinary incontinence, which had been evolving over several months.

Upon admission, vital signs were stable: blood pressure 123/78 mmHg, heart rate 82 bpm, respiratory rate 18 breaths/min, oxygen saturation 98% on room air, body temperature 36.8°C. Clinical examination revealed right flank tenderness without signs of peritonitis. There was no costovertebral angle tenderness. Cardiopulmonary examination was unremarkable.

Initial laboratory investigations are summarized in Table 1, relevant for moderate renal impairment with a serum creatinine of 1.36 mg/dL and an estimated glomerular filtration rate (eGFR) of 48 mL/min/1.73 m². Urea was mildly elevated at 62 mg/dL. Liver function tests showed significant abnormalities with elevated transaminases (AST 98 U/L, ALT 143 U/L), marked elevation of cholestatic enzymes (GGT 1741 U/L, alkaline phosphatase 1081 U/L), and a total bilirubin of 0.28 mg/dL, indicative of cholestasis. Inflammatory markers were moderately elevated with C-reactive protein (CRP) at 15.3 mg/L, while the white blood cell count was normal at 9.81 × 10⁹/L. Urinalysis showed sterile leukocyturie with 450 leukocytes/μL and abundant epithelial cells. Numerous granular casts were observed under microscopy, indicating significant tubular injury. No bacterial growth was detected in urine culture, ruling out infectious etiology.

Abdominal computed tomography (CT) imaging revealed marked dilatation of intra- and extrahepatic bile ducts without lithiasis or obstructive mass (Figures 1 and 2). Additionally, an uneven dilatation of the urinary tract was noted (Figures 3 and 4). The liver parenchyma appeared homogeneous with no focal lesions. Irregular thickening of the bladder and urethral walls was also observed.

Following the initial diagnostic workup, the patient was admitted to the internal medicine department, where she was jointly managed by the gastroenterology and nephrology teams. Despite medical recommendations, the patient elected to leave the hospital against medical advice, before completion of further investigations and initiation of definitive management.

Table 1: Biological findings on the day of admission.

Figure 1: Contrast-enhanced abdominal CT-coronal section. (Note: Dilatation of the biliary ducts (solid black arrow)).

Figure 2: Contrast-enhanced abdominal CT–frontal section. Note: Dilatation of the biliary ducts (solid black arrow).

 Figure 3: Coronal section of contrast-enhanced abdominal CT illustrating pyelocaliceal dilatation (white asterisk).” 

Figure 4: Frontal slice of contrast-enhanced abdominal CT revealing moderate to severe pyelocaliceal dilatation (white asterisk).