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Recreational ketamine use increases risk for biliary tract anomalies

Serum alkaline phosphatase and prior emergency attendance for urinary symptoms among individuals who recreationally used ketamine without concomitant drug use predicted biliary anomalies in magnetic resonance cholangiography, according to recently published data.

“Long-term ketamine use is ... associated with deranged liver biochemistry and biliary tract anomalies, ranging from common bile duct dilatation to intra-hepatic beading and strictures,” Wai-Kay Seto, MD, from the University of Hong Kong, and colleagues wrote. “As ketamine continues to be a drug of widespread recreational use, it is imperative to further understand its effects on the biliary system, the patterns of clinical and radiological presentation, and possible clinical sequelae.”

Between December 2012 and April 2017, Seto and colleagues enrolled 257 Chinese adults who used ketamine recreationally at least two times per month over 6 months within 2 years of enrollment. From this cohort, 155 had elevated serum alkaline phosphatase (ALP) and 81 engaged in concomitant recreational drug use.

Magnetic resonance cholangiography showed biliary tract anomalies in 159 participants, including 73 cases of diffuse extrahepatic dilation and 64 cases of fusiform extrahepatic dilation. Biliary tract anomalies were more common in those with elevated ALP than those with normal ALP (P < .001).

Multivariate analysis showed that sole recreational use of ketamine compared with concomitant recreational drug use (OR = 1.99; 95% CI, 1.11-3.58), elevated ALP (OR = 1.007; 95% CI, 1.002-1.012) and history of emergency attendance for urinary symptoms (OR = 1.95; 95% CI, 1.03-3.7) correlated independently with biliary tract anomalies.

The inter-observer agreement of magnetic resonance interpretation was excellent for the presence of biliary anomalies (K value = 0.89; 95% CI, 0.85-0.94) with a positive agreement of 0.71 (95% CI, 0.58-0.81) and a negative agreement of 0.95 (95% CI, 0.91-0.98).

Serum ALP yielded a better area under curve for biliary tract anomalies among those who solely used ketamine (AUC = 0.8) compared with the overall study cohort (AUC = 0.745) and those with concomitant recreational drug use (AUC = 0.642). Serum ALP of 113 U/L or higher had an overall positive predictive value of 79.3% for biliary tract anomalies and increased to 85.4% among those who solely used ketamine.

The researchers followed 21 patients for a median of 12.1 months (range, 6.1-15.8) and found that six participants with confirmed ketamine abstinence had a mean decrease in extrahepatic ductal diameter of 5.7 mm, whereas the 15 participants who continued ketamine use had a mean increase of 0.7 mm (P < .001). Additionally, those who abstained had a decrease in serum ALP levels of 41 U/L and those who continued use had an increase of 17 U/L (P = .016).

“The long-term clinical outcome of different ketamine-related cholangiopathic patterns is still unknown,” Seto and colleagues wrote. “The present study findings enhance our understanding on ketamine’s toxicities to the biliary tract, and may aid the public health efforts against the growing epidemic of recreational ketamine use.” – by Talitha Bennett

Disclosure: Seto reports he is an advisory board member of Celltrion, Bristol-Myers Squibb and Gilead Sciences; and received speaker fees from AbbVie, Alfa Wassermann, AstraZeneca, Bristol-Myers Squibb and Gilead Sciences.