A young patient with biliary and urinary disease: What's the unifying diagnosis?

Introduction Chronic ketamine abuse is a growing public health concern associated with severe organ damage. While ketamine‐induced uropathy and cholangiopathy are well‐documented complications individually, their simultaneous presentation is rare. This dual‐system involvement, however, provides a key diagnostic clue on imaging. Case Presentation A 37‐year‐old female with a long‐standing history of substance abuse presented with fever, right loin pain, and deranged liver function tests showing a cholestatic pattern. Urgent computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) were performed. Imaging revealed a distinct combination of findings: dilatation of the common bile duct and bilateral hydronephrosis. Key features included diffuse, smooth enhancement of the urothelium and the absence of mechanical obstruction in either the biliary or urinary systems. Conclusion The constellation of non‐obstructive biliary dilatation and inflammatory hydronephrosis is a classic presentation of ketamine‐induced cholangiopathy and uropathy. This case underscored the importance of recognizing this specific dual‐system injury pattern in a young patient. A high index of suspicion is crucial for diagnosis, as the history of illicit drug use is often underreported. Effective multidisciplinary communication is paramount to connect the clinical and radiological findings, ensuring an accurate and efficient diagnosis.