Body packing

Background

Small bowel anatomy with surrounding structures.

Seized cocaine containers (i.e. bodypacks).

Illicit drugs evacuated from a body packer. They are packed tightly and wrapped into aluminum foil.

• Body packers, also called "mules", swallow or insert drug filled packets into body cavity, usually to smuggle them across borders
• Packets usually made of several layers of latex and outer wax coating
• Each packet contains about 10g of drug and body packers ingest between 50 to 100 drug containers at a time
• Sometimes packets are inserted rectally or vaginally
• Distinct from Body stuffing (ingestion of illicit drugs while pursued by law enforcement, usually small quantity)

Foreign Body Types

• Ear foreign body
• Nasal foreign body
• Ocular foreign body
• Aspirated foreign body
• GI
  • Ingested foreign body
    • Bezoar
    • Body packing
    • Esophageal foreign body removal with foley catheter
  • Rectal foreign body
• Soft tissue foreign body

Clinical Features

• Situations in which body packers present to the ED:
  • Asymptomatic but in custody
  • Signs of toxidromes from a ruptured packet
  • Signs of bowel obstruction or perforation
• History and physical
  • Type of drug
  • Type of packet wrapping (more likely to rupture or leak if home made)
  • Number of packets ingested
  • GI symptoms (pain, distention, obstipation)
  • Other drug use

Differential Diagnosis

Drugs of abuse

• 25C-NBOMe‎
• Alcohol
• Amphetamines
• Bath salts
• Cocaine
• Ecstasy
• Gamma hydroxybutyrate (GHB)
• Heroin
• Inhalant abuse
  • Hydrocarbon toxicity
  • Difluoroethane (electronics duster)
• Marijuana
• Kratom
• Phencyclidine (PCP)
• Psilocybin ("magic mushrooms")
• Synthetic cannabinoids
• Chloral hydrate
• Body packing

Evaluation

Abdominal x-ray reveals multiple, oval radiopaque packets throughout the abdomen.

Abdominal X-ray showing swallowed packages of cocaine.

(A) plain x-ray reveals several uniform radiopaque packets; B-C, Abdominal CT scan without oral contrast shows numerous randomly distributed packets within the small bowel and colon. Their density is 150-170HU which is compatible with the density of opium.

• Imaging: KUB, CT abdomen pelvis
• Urine drug screen: may be misleading

Management

• Asymptomatic patients
  • Expectant management, no surgery, close monitoring in ICU until passage of all packets
  • Whole bowel irrigation with polyethylene glycol via NGT at 2L per hour
  • Activated charcoal more useful in body stuffers
• Opioid toxicity
  • Naloxone: may require very high doses
    • 2 to 5mg IV initially, repeat 2mg q5min until responsive
    • then total amount required for response should be given every hour as continuous drip
• Sympathomimetic toxicity
  • Immediate OR for surgical decontamination
  • No place for conservative management
  • Pharmacologic stabilization appropriate but not definitive, do not delay transfer to the OR
    • Hyperthermia
      • Active external cooling
      • IV benzodiazepines (midazolam 1 to 2mg IV or diazepam 5 to 10 mg IV, rapid escalation in dosing)
    • Hypertension
      • IV benzodiazepines, phentolamine, nitroprusside, nitroglycerin,, or nicardipine
    • Seizures
      • IV benzodiazepines, followed by propofol if needed
    • Ventricular dysrhythmias
      • IV benzodiazepines, followed by hypertonic sodium bicarbonate if wide QRS
• Obstruction or perforation
  • OR for immediate ex-lap, then advanced imaging study to document a clear GI tract
  • Endoscopic removal highly controversial, risk of packet perforation

Disposition

• Admit all to ICU, regardless of symptoms
• Complete GI decontamination by contrast CT should be documented prior to discharge
  • History is unreliable
  • Passage of 2 or 3 packet free bowel movements is not sufficient

See Also

• Body stuffing
• Drugs of abuse
• Ingested foreign body
• Rectal foreign body