{'fraction_non_alphanumeric': 0.03143350604490501, 'fraction_numerical': 0.008290155440414507, 'mean_word_length': 5.407079646017699, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Hepatobiliary and Pancreatic: Cholangiopathy in Ketamine user––An emerging new condition

Ketamine, an N-methyl-D-aspartate antagonist, is becoming a popular drug of abuse in the Asian population. The use of this drug could produce short-term sensations of excitement, hallucinations and vivid imagery. The abuse of this drug has also been reported in places outside Asia. As ketamine is mainly excreted in urine and bile, it can cause dysfunction to the urinary bladder and the bililary system. Here, we describe a case of sphincter of Oddi dysfunction in a patient who abused ketamine. A 20-year-old woman with a 2-year history of ketamine abuse presented with right upper quadrant pain, nausea and fever over 2 weeks. On presentation, the patient had a low-grade fever and mild tenderness in the epigastrium, but no jaundice and was normotensive. Laboratory tests showed elevated white cell count with neutrophilia, and cholestatic liver function test derangements, which were characterised by marked elevation of serum alkaline phosphatase (2129 U/L) and to much lesser extend, bilirubin (5 umol/L), serum aspartate aminotransferase (143 U/L) and alanine aminotransferase (178 U/L). She was tested negative for antimitochondrial antibody, anti-nuclear antibody, and anti-HIV antibody. Her serum CA19.9 and immunoglobulin G4 (IgG4) levels were normal. Contrast computed tomography scan showed dilation of both common bile duct (CBD) and intrahepatic ducts, with imaging evidence of hepatic micro-abscesses (Fig. 1). Thus, an endoscopic retrograde cholangiopancreatography (ERCP) was performed and failed to show any filling defects suggestive of stones or sludges in the biliary tract and gallbladder. Instead, a persistent ultra-short narrowing was noted at the very distal portion of CBD, where sphincter of Oddi would be located (Fig. 2). After a carefully performed long sphincterotomy, repeated cholangiogram showed the very distal CBD narrowing had disappeared, and the contrast was flowed freely into the duodenum (Fig. 3). Her liver function returned to normal together with resolution of fever and abdominal pain after the ERCP. Given the important differential diagnoses such as primary sclerosing cirrhosis, recurrent pyogenic cholangitis, IgG4-positive sclerosing cholangitis, and AIDS-cholangiopathy had been excluded, we believe this lady has ketamine-induced chronic cholangiopathy, characterising predominantly by the persistent sphincter of Oddi spasm that lead to biliary obstruction and infection. Although the pathogenesis of bile duct dilatation from ketamine abuse remains unclear, animal studies have demonstrated increased flow resistance across the sphincter of Oddi with ketamine administration, suggesting the potential role of ketamine in inducing sphincter of Oddi dysfunction. Sphincterotomy or sphincteroplasty has been an effective treatment in these patients.