Body packers: the ins and outs of imaging.
- SourceAvailable from: secure.muhealth.orgNew England Journal of Medicine 01/2004; 349(26):2519-26. · 51.66 Impact Factor
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ABSTRACT: Body packing, pushing and stuffing are methods by which illicit drugs may be carried within the human body. Patients involved in these practices may present UK emergency departments with complex medical, legal and ethical considerations. This review article examines not only the evidence behind the clinical management of these patients, but also the legal powers afforded to the authorities to authorise the use of intimate searches and diagnostic imaging for forensic purposes. Serious complications from concealed drug packets are now rare, and most asymptomatic patients may be safely discharged from hospital after assessment. Emergency surgery is indicated for body packers with cocaine poisoning and for some cases of heroin poisoning. Urgent surgery is indicated for obstruction, perforation, the passage of packet fragments and failure of conservative treatment. Guidance is given for doctors who are faced with requests from the authorities to perform intimate searches and diagnostic imaging for forensic purposes.Emergency Medicine Journal 06/2009; 26(5):316-20. · 1.65 Impact Factor
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ABSTRACT: To describe the clinical course of cocaine "bodystuffers" presenting to regional emergency departments, a descriptive retrospective analysis was performed on all cases of cocaine bodystuffers received by a metropolitan poison control center and associated toxicology service from January 1993 to May 1994. We identified 46 cases of patients classified as bodystuffers. Of these, 34 patients (74%) remained asymptomatic. Eight patients (18%) had mild symptoms including hypertension and tachycardia that resolved with no treatment beyond decontamination or benzodiazepines (one patient). Two patients (4%) had moderate symptoms including agitation and fever that resolved with no treatment beyond decontamination or benzodiazepines (one patient). Two patients (4%) had severe symptoms including seizure and cardiac dysrhythmia. Both died. Radiographs of the abdomen were negative for foreign body in all 23 examinations performed. Mild cocaine intoxication is common in cocaine bodystuffers. Severe intoxication can occur, resulting in death. Abdominal radiographs are not of value for stuffers ingesting cellophane-wrapped packets. More experience is needed to determine the length of intensive care monitoring that these patients require.Journal of Emergency Medicine 03/2000; 18(2):221-4. · 1.33 Impact Factor
Abdominal Imaging / Imagerie abdominale
Body Packers: The Ins and Outs of Imaging
Kristy Lee, MDa, Martha Koehn, MDa, Rashin F. Rastegar, MDa,*, Frans van Hoorn, MDb,
Elizabeth Roy, MDc, Ferco H. Berger, MDa, Savvas Nicolaou, MDa
aFaculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
bDepartment of Radiology, Academic Medical Center, University of Amsterdam, Netherlands
cFaculty of Medicine, University of Calgary, Calgary, Alberta, Canada
Key Words: Body packers; Drug packets; Drug smuggling; Double-condom sign; Rosette sign; Cocaine; Heroin; Marijuana
Illicit drug exportation is one of the most influential
factors in the economy in British Columbia. In the marijuana
sector alone, marijuana exports are greater than any of the
province’s legal exports, with sales estimated to be USD$3.8
billion per year. In Canada and the United States, drug
trafficking is a dual offense, punishable up to 5-40 years in
prison, with fines that range from CAD$250,000 to CAD$1
million . To participate in such a lucrative yet risky
industry, many people risk their own lives to turn a profit.
One way that this is accomplished is through ‘‘body
packing,’’ a term first described in Toronto in 1973. It refers
to smuggling drugs via intracorporal means and is used by
80% of apprehended drug smugglers . Drugs are placed in
packets (condoms and/or latex, cellophane, or capsules) and
are either swallowed or inserted rectally or vaginally. The
most commonly smuggled substances in body packing are
cocaine, heroin, and cannabis. Ecstasy, lysergic acid dieth-
ylamide, and hallucinogens are less likely to be smuggled
this way, likely due to less significant financial gain. The
average body packer carries 1 kg of drug (approximately 50
packets), which, in terms of cocaine street value, translates
into a CAD$30,000 profit. Rupture of 1 packet can lead to
life-threatening intoxication . Other medical emergencies,
including bowel obstruction, bowel perforation, and perito-
nitis also frequently occur. Because history, physical exam-
ination, and laboratory tests are often equivocal in detecting
the presence of packets, imaging is an essential tool in the
diagnostic workup of these cases. The following article aims
to elucidate the role of imaging in the evaluation of those
suspected of body packing and provide an overview of the
various signs and findings.
Packet rupture can lead to ‘‘body packer syndrome.’’
Patients may present with a whole spectrum of signs and
stipation, loss of consciousness, and seizures. The major
toxidromes are described in Table 1 [4e6].
Role of Imaging
Currently, there is no criterion standard for the detection
of drug packets. Variations in packet size, substance,
consistency, and purity all contribute to an inconsistent
appearance on imaging. On plain radiographs, it can be
difficult to visualize drug packets, because they may have
a similar appearance to stool or air. They are often mistaken
as air bubbles in the rectum and sigmoid colon . The
appearance of packet size varies, with swallowed packets
appearing small and round, and rectally inserted packets
appearing larger and more oval in shape. Packets that are
handmade often have a wide variation in size and shape,
whereas packets produced mechanically are more uniform.
The density of packets also varies with composition and
purity, and, therefore, heroin, cocaine, and hashish can look
similar on radiographs . The plain radiograph density of
heroin is similar to air, the density of cocaine is less than
water, and that of marijuana is greater than stool . Packets
made of synthetic materials can be easily detectable due to
their high-density edge.
In addition to the fact that drug packets have a heteroge-
neous morphology, which makes them difficult to identify,
* Address for correspondence: Rashin Fallah Rastegar, MD, Department of
Radiology, Vancouver Hospital and Health Sciences Centre, 899 W 12th
Ave, Vancouver, British Columbia V5Z1M9, Canada.
E-mail address: email@example.com (R. F. Rastegar).
0846-5371/$ - see front matter ? 2011 Canadian Association of Radiologists. All rights reserved.
Canadian Association of Radiologists Journal xx (2011) 1e5
there is no perfect imaging modality. There are case reports
of packets missed by plain radiographs and later seen on
computed tomography (CT), and vice versa [4,7]. Similarly,
there have been cases of packets that were missed by CTand
later detected on ultrasound . Magnetic resonance imaging
(MRI) does not play a significant role, not only because of
poor accessibility, but also due to the presence of artifacts.
Overall, multimodal imaging may be the most sensitive and
specific way of detecting drug packets .
Currently, plain radiographs are typically the initial
modality used in drug packet imaging . Detection rate is
positively correlated with the number of packets present.
Thus, plain radiographs have a low sensitivity when only
a small amount of drug is present . Abdominal radiograph
sensitivity for the detection of cocaine drug packets has been
reported to range from 47%-95%, with supine imaging
yielding better results than erect position . The use of
repeated imaging or contrast may improve results, although
false positives can result from constipation induced by
opiate-filled packets or antimotility drugs . Typically,
packets are identified on plain radiographs as uniform,
oblong, hyperdense foreign bodies . Air can be present
between layers of wrapping (double-condom sign) or in knots
within the packets (rosette sign) (Figure 1) . Air leak can
also be seen as a gas halo or a ring shadow . Furthermore,
the arrangement of packets can also lead to a diagnosis, such
as in the case of similar lesions appearing in a row .
Examples potential complications of drug packing, namely
bowel obstruction and perforation are shown in Figure 2.
It has been proposed that CT may be superior to plain
radiographs in detecting drug packets; however, there is little
evidence to support this. Although CT has better quality
contrast resolution and allows overlying structures to be
more clearly delineated, there is no evidence to support
improved sensitivity. Furthermore, false negatives are not
uncommon . When reviewing CTs, detection of drug
packets can be improved by increasing window width and
level settings (width, 1000 HU; level, 2700 HU), in addition
to the usual abdominal window settings (width, 350 HU;
level, 50 HU). The ‘‘air-ring sign’’ (air density around
foreign-body shadow) and ‘‘onion sign’’ (multilayer circular
Decreased LOC; respiratory
depression; pinpoint pupils;
decreased bowel sounds
LOC ¼ loss of consciousness.
aFrom Refs. 4 and 5.
Figure 1. Appearances of packets. (A) A very homogeneous shape of mechanically made packets with ‘‘double-condom sign,’’ vaguely seen circumferentially
around somewhat opaque packets. (B) ‘‘Double-condom sign’’ seen head-on (arrow).
2K. Lee et al. / Canadian Association of Radiologists Journal xx (2011) 1e5
ring-like area) are typically seen on CT and serve as a strong
indicator for the presence of packets (Figure 3) .
Ultrasound is the first choice modality in the detection of
free fluid, which can indicate complications of body packing
such as bowel perforation but has a limited role in the
identification of the actual drug packets . Packets mixed
with stool and gas are often easily missed, and sensitivity is
considered lower than plain radiographs. However, easy
accessibility to ultrasound in the emergency department, lack
of radiation, and lower costs make this modality useful. Drug
packets present as hyperechogenic linear or round structures,
with acoustic shadowing (Figure 4) .
According to Hahn et al , the diagnostic and thera-
peutic workup of body packers entails several steps. For
asymptomatic patients, a plain radiograph should be obtained
for packet detection. The patient should then be given an oral
dose of activated charcoal, as well as whole-bowel irrigation
with a polyethylene glycol electrolyte solution until the drug
packets are evacuated. It is important to remember that
packets may remain in the gastrointestinal tract despite
whole-bowel irrigation, and, thus, subsequent imaging is
crucial to ensure complete evacuation . An upper gastro-
intestinal series with bowel follow-through can be used for
this purpose (Figure 5) . For suspected body packers who
Figure 2. Complications of body packing. (A) Small-bowel packets projecting over the pelvis and causing small-bowel obstruction. (B) Perforation caused by
packets in left upper quadrant (left arrows) as evidenced by suprahepatic free air (right arrow).
Figure 3. Computed tomography appearance of packets. (A) Small-bowel packets (indicated by arrows) stand out by hyperdensity and circumferential air
known as the ‘‘air-ring sign.’’ (B) Increasing window width and level helps detect packets (arrows) not seen on radiographs, with the presence of an ‘‘air-ring
sign.’’ (C) Oral contrast material, masking the presence of packets (arrow) on computed tomography.
3 Body packers / Canadian Association of Radiologists Journal xx (2011) 1e5
(ie, ileus, perforation, drug reaction) require not only the
detection of the packets but also identification of the cause of
the symptoms to better target treatment. In these patients, an
initial ultrasound may be used to detect the presence of free
fluid. Plain radiographs are also recommended for the
detection of drug packets as well as potential complications
(ie, ileus, perforation). If results are still equivocal, a CT of
the abdomen would be prudent. In addition, management
of packet evacuation should be carried out as outlined
Figure 4. Ultrasound appearance of drug packet. (A) Classic echogenic reflection of large packet (outlined by arrows). In this case, the packet migrated, after
vaginal insertion, by eroding through the vaginal wall. The hypoechoic layer is not classic but represents granulation tissue after 2 months. (B) Computed
tomography confirmation of foreign-body material, consistent with packet (arrow).
Figure 5. Use of follow-up studies, including Gastrografin (Schering, Berlin, Germany). (A) Packets delineated by arrows seen in the descending portion of the
colon as well as the ascending portion in the setting of resuscitation. (B) Hours later a follow-up study was performed with Gastrografin to check for residual
packets, confirmed in the full length of the descending colon, seen as lucent structures (arrows) in dense contrast material.
4 K. Lee et al. / Canadian Association of Radiologists Journal xx (2011) 1e5
In Canada and the United States, current regulations state
that customs officers can detain a suspected body packer
until an abdominal radiograph is obtained to rule out the
presence of packets (with the suspect’s consent). If consent is
refused, then the suspect may be held until passage of 2
packet-free bowel movements has occurred .
Imaging plays an essential role in the identification and
management of drug packers. As outlined, each imaging
modality comes with its own utility and limitations.
Although radiography often is considered as the initial
imaging modality of choice, a multimodality approach is
usually indicated. A summary of the signs that can be used to
detect drug packets on radiographic and CT images is
provided in Table 2.
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 June R, Aks SE, Keys N, et al. Medical outcome of cocaine body-
stuffers. J Emerg Med 2000;18:221e4.
 Herger K, Kofler K, Oser W. Drug smuggling by body packing: what
radiologists should know about it. Eur Radiol 2004;14:736e42.
 Yang RM, Li L, Feng J, et al. Heroin body packing: clearly discerning
drug packets using CT. South Med J 2009;102:470e5.
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heroin packet. J Emerg Med 2004;27:279e83.
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Summary of the appearance of drug packets as seen on x-ray films and CT
signRosette signOnion signAir-ring sign
of packet wrapping
between layers of
Seen on CT
Seen on x-ray film Seen on x-ray filmSeen on CT
CT ¼ computed tomography.
aRefs. 4 and 8.
5Body packers / Canadian Association of Radiologists Journal xx (2011) 1e5