Ketamine, a synthetic phencyclidine derivative, is widely used for anaesthesia, analgesia, and treatment-resistant depression, but its hallucinogenic properties have driven increasing recreational misuse. It is metabolised hepatically, with approximately 90% excreted in urine. Ketamine-associated urinary tract injury is well recognised, with severe cases leading to chronic pain and even reconstructive bladder surgery, as highlighted in a recent systematic review of nearly 4,000 patients. 

In contrast, ketamine-induced biliary injury is less well described. A recent systematic review identified only 17 reported cases, yet the consequences can be similarly severe. 

With ketamine use rising across Europe over the past decade, we have observed a growing number of patients presenting with ketamine cholangiopathy. Our aim was to enhance understanding of this emerging condition by collating and analysing our centre’s cases. 

All new referrals to our service are discussed at a weekly multidisciplinary team (MDT) meeting. We reviewed MDT records from 2019, when the hospital transitioned to an electronic health record system, through to July 2025. We collected demographic data, imaging results, frequency of ketamine use, urological involvement, date of referral, endoscopic interventions, symptom history, and liver function test results. 

We identified 18 patients (mean age 32 years) with a mean follow-up of 3.8 years; sex distribution was equal. Seventeen reported weekly ketamine use at peak consumption. Cholangiopathy was evident on imaging in 17 patients, with one additional patient displaying abnormal liver tests while awaiting imaging. Uropathy was present in 14 patients. 

At referral, 13 patients reported abdominal pain. At latest follow-up, 8 were abstinent from ketamine, of whom 5 experienced symptomatic improvement. One patient developed decompensated liver disease and died. Excluding this case, mean bilirubin was 12 µmol/L, ALT 183 U/L, and ALP 474 U/L. Two patients required ERCP for biliary strictures. Five patients underwent repeat imaging after reducing or ceasing ketamine use; one demonstrated complete resolution of cholangiopathy, while the remaining four showed either improvement or stable appearances. 

This is the largest case series to date on recreational ketamine users, underscoring the emerging public health issue of ketamine-induced cholangiopathy, which is closely linked to ketamine-induced uropathy. Most patients can be managed with active surveillance, with few requiring endoscopic intervention. The long-term outcomes remain unclear, though there is concern for progression to cirrhosis or malignancy. Ongoing research and greater awareness are needed given the rising prevalence of illicit ketamine use.