Ketamine-induced cholangiopathy.

Hong Kong Med J ⎥ Volume 20 Number 1 ⎥ February 2014 ⎥ www.hkmj.org A 28-year-old woman presented to us in November 2010 because of deranged liver function test results; predominantly she had raised ductal enzyme levels (gamma-glutamyl transferase, 1088; reference range, 12-57 IU/mL); alkaline phosphatase (ALP) 579 (reference range, 46-127) IU/mL, alanine transaminase (ALT) 183 (reference range, 10-57) IU/mL with normal bilirubin levels. Upon further questioning, she had been a ketamine abuser for 5 years and was followed up by psychiatrists. She was completely asymptomatic and physical examination yielded nil abnormal. Her ALP level was excessive (154 IU/mL) and her ALT level was 48 IU/mL. Ultrasound of hepatobiliary system (HBS) showed a dilated common bile duct (CBD) of 1.1 cm in diameter with tapering over lower end. A gallstone was present in the gallbladder. Therefore, the endoscopic retrograde cholangiopancreatography (ERCP) was performed in November 2011, and showed a 5-cm stricture at the lower end of the CBD together with small bilateral segmental strictures in the intrahepatic ducts (Fig 1). Brush cytology of the stricture of CBD revealed no malignant cells. A plastic stent bypassing the CBD was inserted for drainage. Liver function test findings did not improve after stenting but repeated ultrasonography of the HBS showed that with the 5.7-mm stent in situ, the CBD was not dilated . A liver biopsy was therefore performed, and showed mild-to-moderate portal fibrosis with ductular proliferation (Fig 2) and periportal copper deposits were noted (Fig 3). These findings were consistent with chronic cholestasis at both the extrahepatic and intrahepatic level. There were no features suggestive of primary biliary cirrhosis, or primary sclerosing cholangitis. The colonoscopy was normal and showed no evidence of inflammatory bowel disease. The patient’s liver function improved