W Zuidema, B Veenings
bodypacker, cocaine, drugs, foreign bodies
W Zuidema, B Veenings. Bodypackers: caught in the act.. The Internet Journal of Emergency and Intensive Care Medicine. 2009 Volume 12 Number 1.
Body packing is an international problem in which people smuggle drugs hidden in the gastrointestinal tract after swallowing, across international borders. This way of transportation can have serious medical complications, including gastrointestinal obstruction by the foreign bodies or drug intoxication. We describe three cases of adult bodypackers as well as our management of these patients.
The smuggling of drugs by internal bodily concealment is an increasing international problem. It was first reported in 1975 by Mebanex et al.. Bodypackers are drug smugglers who swallow drug filled condoms or latex multilayer packages in order to conceal them during air travel1,2.
Case 1: A 39 year old man presented to the ER with complaints of pain in the abdomen after ingestion of, according to the patient, 80-100 packages filled with cocaine, one day earlier before flying in from the Caribbean. He complained of nausea and had vomited once. He had not passed any stool or package. On examination he had a distended left upper abdomen without peritoneal involvement. He was hemodynamic stable and showed no signs of cocaine intoxication. Laboratory values were normal.
A plain X-ray of the abdomen was performed showing more than 30 foreign bodies in the stomach without signs of perforation (Fig.1). Based on these findings the diagnosis of asymptomatic body packing was made. Patient was admitted to the ward and under close supervision treatment with sorbitol 70% and oral fluids was installed. After 48 hours there was no progression of the case. A CT of the abdomen was performed which showed multiple foreign bodies still within the stomach with a significant distension of the antrum (Fig.2).
Because there was no progression in the passage of the cocaine packs throughout the gastro-intestinal tract a laparotomy was performed. A gastrotomy was used with the evacuation of 83 packs. One package was palpated in the small bowel, this one was pushed forward and passed the ileocoecal valve. Three days post-operative this last package was retrieved from the stool of the patient. The rest of the post-operative period was uneventful and patient could be discharged.
Case 2: A 22 year old man was brought to the ER by custom service after ingestion two days earlier of 95 packages of cocaine. He had been arrested and detained and 11 packages from his stool were retrieved. He complained of nausea and vomiting. On examination he showed no signs of intoxication. His abdomen was slightly painful on deep palpation in both lower quadrants. There were no signs of peritoneal involvement.
A plain X-ray of his abdomen was performed (Fig.3) showing foreign bodies throughout his abdomen. A CT-scan showed multiple packages confined to his colon, without obstruction or signs of perforation(Fig.4). This asymptomatic bodypacker was admitted and under supervision was treated with sorbitol 70% and oral fluids. Within two days he passed 84 packages in his stool. Three consecutive stools were negative. A control fluoroscopy of his abdomen showed no more packages and he was discharged.
Case 3: A 47 year old male was presented to the ER by custom service eight days after ingestion of packages of cocaine. He had pain localised in his upper gastric region. He had been shortly admitted to another hospital two days after ingestion and been discharged with a prescription for sorbitol. On examination he showed no signs of intoxication. His laboratory values were normal. A plain X-ray of his abdomen (Fig.5) showed a few foreign bodies in his stomach.
A CT scan showed 10 foreign bodies retained in his stomach and one in his ascending colon (Fig.6). Since there were eight days past and there were still packages in his stomach a laparotomy was performed. After gastrotomy 10 packages where retrieved. One package was palpable in his colon transverses. Post-operative he was given oral sorbitol 70% and fluids. Seventy-two hours after admission he passed the last package in his stool. On day five he was discharged.
The number of bodypackers seems to be increasing in the last years. Reliable data about the total number of bodypackers does not exist, since most probably pass unnoticed through customs and require no medical attention. Since the quality of wrapping the packages has improved, fewer patients present with intoxication but more with abdominal complaints or failure to pass all their packages due to internal obstruction which increases the chance of rupture. Another reason for presentation is referral of patients after arrest for medical assessment and observation3,4,5,6. The diagnose can be made using medical history and radiographic imaging. The plain abdominal radiography is the most useful screening tool with a sensitivity of 85 till 90%. Although hard figures are lacking, CT scan or contrast-enhanced abdominal radiography is expected to be even more sensitive. In our institution we use a plain abdominal film for screening of presents of foreign bodies. In positive cases a CT- scan of the abdomen is performed which gives information about the exact number, location and presence of perforation or obstruction. It is important to rule out in a cocaine bodypacker signs of intoxication such as anxiety, dilated pupils, diaphoresis, tachycardia, hypertension, seizures or cardiovascular collapse.
The asymptomatic cocaine bodypacker can be treated with a laxative like sorbitol 70% under close monitoring. Stools should be checked for packages. After 3 consecutive negative stools a control radiographic study should be performed to check for any left package. In case of signs of intoxication or bowel obstruction, direct surgical intervention is indicated ². Retention of packages more than 48 hours inside the stomach is another reason for direct laparotomy. The stomach with its continuous production of acid can lead to leakages of the packages if they do not pass into the small bowel within 48 hours. This can lead to a life threatening intoxication. In case of surgery postoperative a final radiographic study of the abdomen should be performed to rule out missed packages during operation7,8,9.