Ketamine-induced sclerosing cholangitis

Case: 72-year-old male ventilated in ICU after severe community-acquired pneumonia has been sedated on Ketamine infusion. On the fifth day of infusion, the patient's alkaline phosphatase is markedly elevated, and a liver ultrasound is negative for calculi or acalculous cholecystitis. What's the probable diagnosis?

Answer: Ketamine induced sclerosing cholangitis

In the last few years, ketamine has become widely popular in ICUs as a sedative agent. Less appreciated is ketamine induced sclerosing cholangitis and liver injury, particularly in ventilated patients who may require prolonged sedation, as it appears to be a dose-dependent effect. Ketamine infusion may be associated with sclerosing cholangitis, jaundice, decompensated cirrhosis, and even fatal acute liver failure (ALF).

#toxicity

#pharmacology

References:

1. Keta-Cov research group. Electronic address: vincent.mallet@aphp.fr, Keta-Cov research group. Intravenous ketamine and progressive cholangiopathy in COVID-19 patients. J Hepatol 2021; 74:1243.

2. de Tymowski C, Dépret F, Dudoignon E, et al. Ketamine-induced cholangiopathy in ARDS patients. Intensive Care Med 2021; 47:1173.

3. Vanrusselt A, Nijs J, Van den Bergh L, Schoofs N, Smets S, Strybol D, Rappaport A. Ketamine-induced sclerosing cholangitis: a case series. Acta Gastroenterol Belg. 2025 Jul-Sep;88(3):271-276. doi: 10.51821/88.3.13914. PMID: 41083171.