1348 The Ketamine Connection: Ulcerative Cystitis and Biliary Dilatation in the Setting of Chronic Ketamine Abuse

Introduction: Recreational ketamine abuse can present with a unique constellation of symptoms, and limited literature on this topic makes this case a rare learning opportunity. CASE DESCRIPTION/METHODS: A 37-year-old male with diffuse psoriasis and a one-year-history of ketamine inhalation presented to the ER complaining of recurrent episodes of epigastric pain. The pain was described as colicky, non-radiating, and 10/10 in intensity; he related the pain acutely worsened in the 3 days prior to admission. He also had a remote history of cocaine and marijuana abuse. He denied vomiting, diarrhea, melena, dysphagia, odynophagia, fevers, or chills. Physical exam findings were negative for a Murphy's sign. Laboratory studies were significant for eosinophilia and an elevated lipase. A CT of the abdomen revealed hypodensities in the liver parenchyma and dilatation of the intrahepatic biliary ducts, common bile duct, gallbladder, and pancreatic duct. These findings suggested an obstructing stone or mass lesion at the ampulla. Furthermore, a pelvic CT also revealed an asymmetric, markedly thickened anterior urinary bladder wall and bladder dome; these findings were concerning for underlying malignancy of the bladder. A urinalysis revealed elevated white blood cells and red blood cells, but cytology was negative. A re-evaluation of the patient revealed symptoms of difficulty urinating, with sensation of having to push to void and dysuria at the end of micturition. Of note, the patient denied any history of freshwater swimming or exposure to factory chemicals. The patient underwent an EUS, which revealed a dilated common bile duct without stones, an acalculous gallbladder, and a deformed ampulla. A bedside cystoscopy was performed, revealing no tumors or strictures, but revealed a high-riding median lobe of the prostate at the bladder neck. Additionally, the posterior dome showed a thickened, erythematous area, and another rounded area consistent with ulcerative cystitis. Urology scheduled the patient for a repeat cystoscopy with biopsy, but unfortunately he left against medical advice as his pain and other symptoms had resolved.

Discussion: Ketamine, known for its hallucinogenic effects, is used recreationally among various populations. Hepatic-dominant metabolization, with urinary (90%) and biliary (10%) excretion leave these organs exposed to ketamine metabolites and their effects. This case emphasizes the importance of drug history in patients presenting with biliary colic and urinary symptomatology.