Imaging of Drug Smuggling by Body Packing

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Imaging of Drug Smuggling by Body Packing
Giacomo Sica, MD, PhD, Franco Guida, MD, Giorgio Bocchini, MD,
Francesco Iaselli, MD, Isabella Iadevito, MD, and Mariano Scaglione, MD
Body packing, pushing, and stuffing are hazardous practices with complex medicolegal and
social implications. A radiologist plays both a social and a medicolegal role in their assess-
ment, and it should not be limited only to the identification of the packages but must also
provide accurate information about their number and their exact location so as to prevent any
package remains in the body packer. Radiologists must also be able to recognize the
complications associated with these risky practices. Imaging assessment of body packing is
performed essentially through plain abdominal X-ray and computed tomography scans.
Ultrasound and magnetic resonance imaging, although with some advantages, actually have
a limited use.
Semin Ultrasound CT MRI 36:39-47 C2014 Elsevier Inc. All rights reserved.
Introduction
T
he term “body packer”generally describes a drug courier
who conceals a large amount of properly wrapped pack-
ages containing illicit substances in the alimentary tract,
1
usually by ingesting them, to carry them commonly across
international borders; sometimes, they insert the packets
rectally or vaginally.
2-4
Body packing is a practice known since 1973 when Deitel
and Syed,
5
first described a case of body packing complicated
by small bowel obstruction after swallowing a condom filled
with hashish.
Body packers are known by many different names such as
“swallowers,”“internal carriers,”“couriers,”or “mules,”
6,7
but 2
other terms have been often used to describe drug carriers:
“body pusher”and “body stuffer.”The “body pushers”hide few
drug containers in a body cavity such as the rectum or
vagina
8,9
; these packages are commonly bigger than those
swallowed (Fig. 1). The “body stuffer,”also called “mini-
packer,”is usually street dealer, often abuser himself, who
ingests small amounts of grossly wrapped narcotics, plastic
pouches, or small pellets to avoid arrest as soon as he meets law
enforcement (Fig. 2).
10,11
The morphologies and dimensions of the packages are
different, depending on whether they are produced
mechanically or manually or whether they are ingested or
introduced into the rectum or in the vagina.
The mechanically produced packets have a regular mor-
phology compared with those manually wrapped. The orally
swallowed packets are usually round in shape and smaller in
size (o2 cm). The genitally inserted packets are normally oval
in shape and larger in size, measuring 4-6 cm in length and
2-3 cm in width.
12-14
Body packers generally carry about 1 kg of a narcotic,
separated into 50-100 packets of 8-10 g each, although more
than 200 packets have been described in individual
smugglers.
11
The packets typically contain cocaine, heroin, or cannabis
products, whereas hallucinogens or synthetic drugs, such as
ecstasy, lysergic acid diethylamide platelets, and amphet-
amines, are rarely found in body packers.
12,15
The drug is compressed into a balloon, in the finger of latex
gloves, or in condoms. In recent years, there has been a
significant change in the methods of packaging, and profes-
sional drug smugglers may now use multilayered, tubular latex
wrapping with a smooth tight tie at each end, less prone to
breakage.
16,17
Body packing is a hazardous practice in which radiologists
play a key role, with medical and legal consequences.
12
In fact,
by the radiologist depends on the issue or the arrest of a suspect
and the possible deprivation of liberty of an innocent in the
case of false-positive reports with significant ethical implica-
tions and extra costs to the authorities and embarrassment to
the on-call hospital interpreting the images.
10,18
Radiological assessment is not only limited to the identi-
fication of packets but must also provide precise information
http://dx.doi.org/10.1053/j.sult.2014.10.003
39
0887-2171/&2014 Elsevier Inc. All rights reserved.
Department of Diagnostic Imaging, Pineta Grande Medical Center, Castel
Volturno, Caserta, Italy.
Address reprint requests to Mariano Scaglione, MD, Department of Radiology,
Pineta Grande Medical Center, Via Domitiana km 30, 81030, Castel
Volturno, Caserta, Italy. E-mail: mscaglione@tiscali.it

about their number and exact location, both to ensure that
none remains before the release of the suspect to the legal
authorities and to recognize mechanical or systemic compli-
cations induced by the drug-filled ingested packets or their
rupture. In fact, in medical literature, there have been some
reported cases of mortality in body packers due to esophageal
and bowel perforation,
19-21
gastrointestinal (GI) ulceration,
22
and obstruction or acute drug toxicity during internal trans-
portation of heroin,
19
cocaine, or cannabis.
23-25
In the radiological report, it is also essential to specify the
exact location of the packages in case of emergency surgical
treatment reserved for the life-threatening complications of
drug-packet ingestion.
26
Enterotomy is necessary to evacuate
packages in the small bowel, distal to the ligament of Treitz,
whereas packages in the stomach and duodenum should be
evacuated through separate incision—gastrotomy with possi-
ble help of endoscopy for packages in duodenum.
24
Rupture or leakage may occur either by mechanical move-
ment or by chemical digestion caused more often by gastric
acid. Body stuffers can show more frequent symptoms of
intoxication than body packers because of the relatively poor
quality of packaging material used and because generally the
rupture of packages seems to happen when the packages are
still located in the stomach (Fig. 3). For this reason, even if the
optimal imaging modality to evaluate body stuffers is poorly
delineated,
27
radiologists should pay more attention to this
category of traffickers.
Imaging assessment of body packing is performed through
plain abdominal X-ray, computed tomography (CT), and less
frequently, ultrasound (US) imaging. Magnetic resonance
imaging (MRI), even if it could be a reliable and valuable
method of assessing body packing,
28
actually has a limited
value.
4,14
Plain abdominal radiography
Abdominal X-ray obtained in an upright and supine position is
the modality most commonly used for initial screening.
26,27
In medical literature an extremely varied sensitivity is reported
in diagnosis of body packing, ranging from 40%-
100%.
2,11,26,29-34
Abdominal plain film sensitivity is directly
proportional to the dimensions of the packets; thereby it is
lower in case of body stuffers because of the small size and
amount of drugs ingested.
9,34
Abdominal radiography cannot be reliable to detect packets
when the radiologist is not confident in his or her interpreta-
tion, and it can often be difficult to reach a correct diagnosis
34
;
stool or gas within the intestine may also resemble ingested
foreign bodies, in addition the low contrast resolution of this
imaging method, form, low number, and position of the
packets may hinder the correct identification of the packages
(Fig. 4).
35
False-negative results may arise when there is no
clear delineation between the packets and the bowel con-
tents.
36
Furthermore, body packers attempt to conceal the
Figure 1 Female body pusher. Axial unenhanced CT. Drug packets located in the vaginal cavity (arrows) and in the rectum
(arrowheads).
Figure 2 Axial unenhanced CT scan in a body stuffer demonstrates the
presence of 2 small packets in the stomach. The packages have a
similar density to the gastric material and only the identification of a
particular disposition of the trapped air (double-condom sign)
through an appropriate CT window allows for their identification.
G. Sica et al.
40

packets by ingesting water, oil or other liquids with similar
radiographic density that do not allow to differentiate
packets from the intestinal content
12
or, in other cases, they
can use more sophisticated smuggling techniques by using
aluminum foil, plastic food wrap, or carbon paper to vary the
radiodensity of ingested drug packets. These new clever
practices can cause more false-negative results.
7
Some authors
proposed to perform in these patients contrast-enhanced
abdominal radiography that can identify drug packets as filling
defects within the contrast medium.
37
Marc et al
2
proposed
oral administration of water-soluble contrast medium for
medical management of cocaine body packers; they reported,
although in 1 patient a single packet was missed, that the
sensitivity of this method ranged from 91.7%-100% during the
first3daysandbothfalse-positive and false-negative rates were
about 4%.
However, this method is more intrusive, as large quantities
(up to a liter) of contrast agent need to be ingested and a further
period of 20-120 minutes has to elapse before the contrast
agent opacifies the small and large bowel. On the contrary,
other authors argue that an administration of the oral contrast
could mask packets that may be situated anywhere in the
digestive tract, does not improve sensitivity, especially for
identification of the small-sized cocaine-filled packets, and may
cause an intraluminal diuresis, which may lead to intestinal
obstruction.
4,10
Repeated plain radiographs may improve results, although
false positives can result from constipation induced by
opiate-filled packets or antimotility drugs that body packers
often take on.
38
Some authors have tried to differentiate the various types of
drugs from their radiopacity.
39-41
The density of cocaine is
Figure 3 Unconscious female body packer. Two axial non-contiguous contrast-enhanced CT images show the presence of
some hyperdense packets in the stomach. Some of these packages had uniform density and smooth margins (A—arrow),
while others, strongly suspected of rupture, showed inhomogeneous density and irregular borders (A and B—arrowheads).
In particular, the margin of an ovule seemed interrupted by a small air bubble (A—arrowhead).
Figure 4 False-negative result on abdominal plain film radiograph (A). Unenhanced axial CT image of the same body stuffer
shows a small packet hyperattenuated to the surrounding gastric content (B—arrow).
Imaging of drug smuggling by body packing
41

more like feces or water, heroin tends to be less dense than
feces, whereas cannabis is more dense than feces.
40,42
However, many times, the radiological opacity of a drug
depends on the composition with other substances or its grade
of purity and often it is strongly correlated to the grade of its
compression, the substance form (eg, a compressed powder or
paste or a crystallized substance), and the manufacturing
process and coating.
9-27
Typically, on plain abdominal radiographs, drug materials
appear as multiple uniformly spherical or oval-shaped foreign
bodies of similar density to feces, while the wrapping materials
can be of higher density, allowing more accurate visualization
(Fig. 5). However, in more than 60% of cases, the wrapping
material cannot be easily seen, leading to false-positive and
false-negative results.
4
The typical findings in the body packing
practice are as follows: (1) the “double-condom sign,”defined
as a clear crescent of air bordering an ovoid opacity (Fig. 6)
43
;
(2) the “tic-tac sign,”extremely common, defined as a smooth
and uniformly shaped oblong structures (Fig. 6); (3) the
“parallelism sign,”not common but highly specific, defined as
firm packages aligning parallel to each other in the bowel
lumen (Fig. 6)
4
;or(4)the“rosette sign,”caused by the air
inclusion in a twisted end of a package.
44,45
On plain
abdominal films, calcifications, scybalous masses, and other
foreign bodies can show false-positive results.
33,46-49
CT imaging
CT is superior in sensitivity, specificity, positive predictive
value, and negative predictive value to the plain abdominal
film in evaluation of body packing because of its improved
contrast resolution and the absence of projections of over-
lapping structures on the transversal sections. Its sensitivity
ranges from 95.6%-100%.
27,36
Packets with a higher attenu-
ation than soft tissue (30-70 HU) are easily identified,
9
and for
this reason, CT scan can facilitate medicolegal management of
body stuffers.
9,50,51
Unenhanced CT is generally sufficient to
identify the packets and their number and exact location,
whereas intravenous contrast media injection is useful for the
identification of any associated complications, such as intesti-
nal perforation or obstruction, usually located at the ileocecal
valve.
35,43,52,53
CT can also identify the ruptured packets,
which present with irregular contours, smaller in size and with
a different density than the undamaged containers (Fig. 3).
14
Oral or rectal administration of contrast medium does not
improve detection of ingested drug-filled packets, and on the
contrary, a case of its failure in detection of a residual packet
has been reported.
54,55
Before performing the CT scan, the scout view should be
examined. CT scout views in 2 planes provide a good grade of
delineation and sensitivity: 5 times higher than conventional
radiography at less than one-third of the radiation dose.
56
Knowledge of the time of ingestion is useful to predict the
anatomical location of suspected drug packets, and it could be
often crucial, on CT examination, to assess the entire GI tract
carefully, from the esophagus (Fig. 7) to the rectum. A great aid
to correctly identify the “ovules”may be the use of multiplanar
reconstructions (Fig. 7).
The ingested packets appear as multiple uniform round-
to-oval dense foreign bodies in the lumen of the GI system
(“tic-tac sign”)(Fig. 8). Both the “rosetta sign”and the “double-
condom sign”are better seen on CT than on plain radiography,
Figure 5 Abdominal radiograph shows multiple ovoid and uniformly
shaped packets in the rectum. The high density of the wrapping
material allows a more accurate visualization of the foreign bodies
(arrows).
Figure 6 Plain abdominal film showing typical findings in body
packing practice: the double-condom sign is seen as lucent rims
around dense packets (arrowheads), the parallelism sign defined as
firm packages aligning parallel to each other in the bowel lumen
(arrows) and the tic-tac sign (in the white box).
G. Sica et al.
42

and the last one is considered the key feature not only in the
assessment of body packers but also in that of body stuffers
(Figs. 2,9,and10).
27
It is sometimes possible to observe large
ovules containing smaller packets (Fig. 11).
It is highly advised to manipulate the CT window to identify
the packets, especially the small ones, partially isodense or even
hypodense packs of the body stuffers that may look like feces
in the bowel loops or food not digested in stomach. Therefore,
it is important to view images in the modifying window not
only using standard abdominal window (level 40/width 400)
but also with an alternate window (eg, level 175/width 600)
or directly by lung window (level 2700/width 1000 HU).
10,57
Scans that initially show no remarkable findings in the
abdominal window may reveal the presence of a concealed
container using an altered window that allows to better identify
the trapped air in the packages eventually placed in an
anomalous position (Fig. 12).
With CT it is also possible to measure, both in vitro and
in vivo, the density of a suspect structure which may be
indicative for a specifictypeofdrugdistinguishing,for
example, heroin and cocaine.
40,58,59
In particular, despite the
composition and purity of the drug, the modality and materials
of packaging may alter the density of the packets. Wackerle
et al
40
showed the density of different drugs on plain film and
CT scan reporting hashish density similar to bone (700 HU),
cocaine density less than fat (219 HU), and heroin density
between fat and air (520 HU). Differentiation of cocaine- and
heroin-containing body packs is also improved using low tube
voltage and the dual-energy index, as reported from Leschka
et al.
60
Despite CT being a very accurate diagnostic tool, it is less
frequently used than plain abdominal radiographs because of
the excessive ionizing radiation burden (radiation exposure of
up to 10 mSv),
61-64
its costs, and the used time and resources.
Therefore, some authors suggest the use of abdominal X-ray as
screening modality to confirm packet retention and, in case of
doubt or in those with no remarkable findings on abdominal
radiographs but strongly suspected of being drug couriers, the
use of abdominal unenhanced CT scan, which is better if
performed a with low-dose protocol with reduced mAs
(30mAs),deliveringadoseofradiationclosetothatofan
abdominal plain film.
34,65,66
Figure 7 Axial CT scan showing the presence of a small package in the thoracicesophagus (A—arrow). Coronal multiplanar
reformatted CT image allows to specify the exact number of packets just swallowed (B—arrows). Two of the three small
packages (C).
Imaging of drug smuggling by body packing
43

Figure 8 Topogram (A), coronal multiplanar reformatted (B), and 3D volume-rendered (C) CT images showing the tic-tac
sign. Multiple drug packets evacuated from the body packer (D). 3D, dimensional.
Figure 9 Sagittal multiplanar reformatted CT image. A large ovule
inserted into the rectum with a clear “double-condom sign”(arrows).
Figure 10 Axial unenhanced CT showing a gastric isoattenuated ovule
containing heroin with a well-identifiable “double-condom sign”
(arrows).
G. Sica et al.
44

US imaging and MRI
Ultrasonography is a fast, radiation-free, and inexpensive
alternative procedure to evaluate body packers.
67,68
In expe-
rienced hands, sonography is a specific test, but its sensitivity is
considered lower than that of plain abdominal film and
decreases when packets are mixed with compact echogenic
stool and gas.
38
Although some reports have shown the value
of US in detection of containers inserted in the vagina,
69
others
showed its equal sensitivity and specificity compared with
abdominal X-ray to detect containers,
30,70,71
and although
Meijer and Bots
67
reported that a positive result on US
examination increased the likelihood of drug containers being
present up to 97.6% (positive predictive value) with an
accuracy of 94%, we cannot exclude the presence of ingested
drug packets with a negative result on US examination.
On US, the packets appear as linear, arcuate, oval or round,
smooth, hyperechogenic structures, with posterior acoustic sha-
dowing (Fig. 13). They are better detected if the hollow viscus is
filled with fluid; fluid in fact behaves as a window and makes the
containers more clearly identifiable. US examination can also
identify the signs of a complication associated with the body pack-
ing practice, such as the presence of abdominal free fluidincaseof
perforation or fluid dilatation of the loops in obstruction.
72-74
The disadvantages of US are its failure to identify the exact
number of packages, to differentiate the types of drugs, and to
be highly operator dependent.
MRI is of limited value both because of its lack of protons
and because a correct small bowel MRI study requires ingesting
a large amount of oral contrast and administration of spasmo-
lytic agents to immobilize the bowel loops to avoid artifacts
from the peristaltic movement.
4
Figure 11 Axial unenhanced CT shows a case of body pushing with a drug-filledcondomintherectum.Eachpackage
contains multiple smaller pellets.
Figure 12 Axial CT images. Using an abdominal CT window, packages in the stomach are hardly detectable (A). Typically,
the air bubbles tend to be disposed in the surface; modifying the CT window, however, the identification of an unusual
declivous position of the air trapped in the packages (B—arrows) allows an easier recognition of the packages that are
isoattenuated to the gastric contents.
Imaging of drug smuggling by body packing
45

Furthermore, MRI is a time-consuming modality and does
not allow differentiation of the types of drugs.
40
Despite these
limitations, Bulakci et al
28
encourage its use in asymptomatic
body packers detection, as it is devoid of ionizing radiation and
able to obtain accurate images of the GI tract.
Conclusion
Body packing, pushing, and stuffing are practices with
complex medicolegal and social implications. Clinical exami-
nation and urine toxicology are mostly unhelpful. Therefore, a
radiologist plays a critical role, not only in confirming the
suspicion of the effective presence of packets in the GI tract but
also in taking an active part in the medical management of
traffickers, especially in case of complications, having to
determine the exact number and location of packages for their
eventual surgical removal. Professional drug smugglers often
try to disguise them from radiologists and the identification of
packages, especially in body stuffer, can become a real radio-
logical challenge. Noncontrast CT is a fast and accurate
diagnostic tool with high sensitivity and specificity in body
packing evaluation. However, because of its high radiation
exposure, abdominal radiography is preferred for initial
screening. In case of a negative result on an X-ray that does
not rule out body packing, an unenhanced CT scan must be
performed to confirm the diagnosis. A low-dose CT scan could
be a valid alternative in the detection of ingested drug packets.
Acknowledgments
The authors acknowledge Mr. Walter Intilla, Nicola Bonaccio,
and Giuseppe Poccia from Nucleo Operativo Carabinieri of
Mondragone for their support and help.
References
1. Smith MT, Wong RK: Foreign bodies. Gastrointest Endosc Clin N Am
17:361-382, 2007
2. Marc B, Braud FJ, Aelion MJ, et al: The cocaine body-packer syndrome:
Evaluation of a method of contrast study of the bowel. J Forensic Sci
35:345-355, 1990
3. Krishan A, Brown R: Plain abdominal radiography in the diagnosis of the
‘‘body packer”. J Accid Emerg Med 16:381, 1999
4. Niewiarowski S, Gogbashian A, Afaq A, et al: Abdominal X-ray signs of
intra-intestinal drug smuggling. J Forensic Leg Med 17:198-202, 2010
5. Deitel M, Syed AK: Intestinal obstruction by an unusual foreign body.
Can Med Assoc J 109:211-212, 1973
6. Prabhu R, Ne’eman A, Bier K, et al: Radiology of body packers: The
detection of internally concealed illegal materials. Appl Radiol 5:26-28,
2008
7. Shahnazi M, Sanei Taheri M, Pourghorban R: Body packing and its
radiologic manifestations: A review article. Iran J Radiol 8:205-210,
2011
8. Schaper A1, Hofmann R, Bargain P, et al: Surgical treatment in cocaine
body packers and body pushers. Int J Colorectal Dis 22:1531-1535,
2007
9. FlachPM,RossSG,AmpanoziG,etal:“Drug mules”as a radiological
challenge: Sensitivity and specificity in identifying internal cocaine in body
packers, body pushers and body stuffers by computed tomography, plain
radiography and Lodox. Eur J Radiol 81:2518-2526, 2012
10. Pinto A, Reginelli A, Pinto F, et al: Radiological and practical aspects of
body packing. Br J Radiol 87:20130500, 2014
11. Traub SJ, Hoffman RS, Nelson LS: Body packing—The internal conceal-
ment of illicit drugs. N Engl J Med 349:2519-2526, 2003
12. Hergan K, Kofler K, Oser W: Drug smuggling by body packing: What
radiologists should know about it. Eur Radiol 14:736-742, 2004
13. Benjamin F, Guillaume AJ, Chao LP, et al: Vaginal smuggling of illicit
drug: A case requiring obstetric forceps for removal of the drug container.
Am J Obstet Gynecol 171:1385-1387, 1994
14. Ab Hamid S, Abd Rashid SN, Mohd Saini S: Characteristic imaging
features of body packers: A pictorial essay. Jpn J Radiol 30:386-392, 2012
15. Bin Abdul Rashid SN, Rahim AS, Thali MJ, et al: Death by ‘ice’:Fatal
methamphetamine intoxication of a body packer case detected by
postmortem computed tomography (PMCT) and validated by autopsy.
Forensic Sci Med Pathol 9:82-87, 2013
16. McCarron MM, Wood JD: The cocaine ‘body packer’syndrome.
Diagnosis and treatment. J Am Med Assoc 250:1417-1420, 1983
17. Pidoto RR, Agliata AM, Bertolini R, et al: A new method of packaging
cocaine for international traffic and implications for the management of
cocaine body packers. J Emerg Med 23:149-153, 2002
18. Sormaala MJ, Salonen HM, Mattila VM, et al: Feasibility of abdominal
plain film images in evaluation suspected drug smuggler. Eur J Radiol
81:2118-2121, 2012
19. Hutchins KD, Pierre-Louis PJB, Zaretski L, et al: Heroin body-packing:
Three fatal cases of intestinal perforation. J Forensic Sci 45:42-47, 2000
20. Johnson JA, Landreneau RJ: Esophageal obstruction and mediastinitis:
A hard pill to swallow for drug smugglers. Am Surg 57:723-726, 1991
21. Dunne JW: Drug smuggling by internal bodily concealment. Med J Aust
2:436-439, 1983
22. Miller JS, Hendren SK, Liscum KR: Giant gastric ulcer in a body packer.
J Trauma 45:617-619, 1998
23. Koehler SA, Ladham S, Rozin L, et al: The risk of body packing: A case of a
fatal cocaine overdose. Forensic Sci Int 30:81-84, 2005
24. Israelit SH, Brook OR, Molnarb R, et al: CT of cocaine carrier—“body
packer”—interpretation requirements. Eur J Radiol Extra 72:e1-e3, 2009
25. Cawich SO, Downes R, Martin AC, et al: Colonic perforation: A lethal
consequence of cannabis body packing. J Forensic Leg Med 17:269-271,
2010
26. Booker RJ, Smith JE, Rodger MP: Packers, pushers and stuffers–managing
patients with concealed drugs in UK emergency departments: A clinical
and medicolegal review. Emerg Med J 26:316-320, 2009
27. Schmidt S, Hugli O, Rizzo E, et al: Detection of ingested cocaine-filled
packets—Diagnostic value of unenhanced CT. Eur J Radiol 67:133-138,
2008
Figure 13 Abdominal ultrasound of a body packer. An oval hyper-
echogenic structure with posterior acoustic shadowing (arrows),
corresponding to a rectal package.
G. Sica et al.
46

28. Bulakci M, Ozbakir B, Kiris A: Detection of body packing by magnetic
resonance imaging: A new diagnostic tool? Abdom Imaging 38:436-441,
2013
29. de Beer SA, Fa-Si-Oen PR: Diagnosis of heroin body packing using
computed tomography. South Med J 102:450-451, 2009
30. Hierholzer J, Cordes M, Tantow H, et al: Drug smuggling by ingested
cocaine-filled packages: Conventional X-ray and ultrasound. Abdom
Imaging 20:333-338, 1995
31. Wong G, Lai K, Chung C: Management of body packers in the emergency
department. Hong Kong J Emerg Med 12:112-118, 2005
32. Bogusz MJ, Althoff H, Erkens M, et al: Internally concealed cocaine:
Analytical and diagnostic aspects. J Forensic Sci 40:811-815, 1995
33. Karhunen PJ, Suoranta H, Penttila A, et al: Pitfalls in the diagnosis of drug
smuggler’s abdomen. J Forensic Sci 36:397-402, 1991
34. Poletti PA, Canel L, Becker CD, et al: Screening of illegal intracorporeal
containers (“body packing”): Is abdominal radiography sufficiently
accurate? A comparative study with low-dose CT. Radiology 265:
772-779, 2012
35. Bulakci M, Kalelioglu T, Bulakci BB, et al: Comparison of diagnostic value
of multidetector computed tomography and X-ray in the detection of
body packing. Eur J Radiol 82:1248-1254, 2013
36. YangRM,LiL,FengJ,etal:Heroinbodypacking: Clearly discerning drug
packets using CT. South Med J 102:470-475, 2009
37. Gherardi R, Marc B, Alberti X, et al: A cocaine body packer with normal
abdominal plain radiograms. Value of drug detection in urine and con trast
study of the bowel. Am J Forensic Med Pathol 11:154-157, 1990
38. Lee K, Koehn M, Rastegar RF, et al: Body packers: The ins and outs of
imaging. Can Assoc Radiol J 63:318-322, 2012
39. Freislederer A, Bautz W, Schmidt V: Body packing: The value of modern
imaging procedures in the detection of intracorporal transport media.
Arch Kriminol 182:143-153, 1988
40. Wackerle B, Rupp N, von Clarmann M, et al: Demonstration of narcotic
packages in “body packers”by various imaging methods. In vitro and
in vivo investigations. Fortschr Roentgenstr 145:274-277, 1986
41. Luburich P, Santamaria G, Thomas X, et al: The gastrointestinal conceal-
ment of illegal drugs. Rev Esp Enferem Dig 79:190-195, 1991
42. Algra P, Byron B, Roque M: Role of radiology in a national initiative to
interdict drug smuggling: The Dutch Experience. Am J Roentgenol
189:331-336, 2007
43. ChaljubG1,ShahRK,LimonD,etal:CTofsmallbowelobstruction
secondary to a cocaine-filled condom. Emerg Radiol 9:333-335, 2002
44. Sinner WN: The gastrointestinal tract as a vehicle for drug smuggling.
Gastrointest Radiol 6:319-323, 1981
45. Traub SJ, Kohn GL, Hoffman RS, et al: Pediatric “body packing”.Arch
Pediatr Adolesc Med 157:174-177, 2003
46. Grassi R, Pinto A, Valente T, et al: Massive enterolithiasis associated with
ileal dysgenesis. Br J Radiol 70:207-209, 1997
47. Grassi R, Pinto A, Rossi E, et al: Nine consecutive patients with gallstone
ileus. Personal experience. Radiol Med 95:177-181, 1998
48. Hunter TB, Taljanovic MS: Foreign bodies. Radiographics 23:731-757,
2003
49. Traub SJ, Hoffman RS, Nelson LS: Falsepositive abdominal radiography in
a body packer resulting from intraabdominal calcifications. Am J Emerg
Med 21:607-608, 2003
50. Pollack Jr CV, Biggers DW, Carlton Jr FB, et al: Two crack cocaine body
stuffers. Ann Emerg Med 21:1370-1380, 1992
51. Nordt SP, Fuchs MA: Clinical course of crack cocaine body stuffers.
Ann Emerg Med 30:714-715, 1997
52. Rousset P, Chaillot PF, Audureau E, et al: Detection of residual packets in
cocaine body packers: Low accuracy of abdominal radiography—a
prospective study. Eur Radiol 23:2146-2155, 2013
53. Desser TS, Gross M: Multidetector row computed tomography of small
bowel obstruction. Semin Ultrasound CT MR 29:308-321, 2008
54. Cranston PE, Pollack Jr CV, Harrison RB: CT of crack cocaine ingestion.
J Comput Assist Tomogr 16:560-563, 1992
55. Hahn IH, Hoffman RS, Nelson LS: Contrast CT scan fails to detect the last
heroin packet. J Emerg Med 27:279-283, 2004
56. Ziegeler E, Grimm JM, Wirth S, et al: Computed tomography scout views
vs. conventional radiography in body-packers—delineation of body-
packs and radiation dose in a porcine model. Eur J Radiol 81:3883-3889,
2012
57. Sengupta A, Page P: Window manipulation in the diagnosis of body
packing using computerized tomography. Emerg Radiol 15:203-205,
2008
58. Grimm J, Wudy R, Ziegeler E, et al: Differentiation of heroin and cocaine
using dual-energy CT-an experimental study. Int J Legal Med 128:
475-482, 2014
59. Grabherr S, Ross S, Regenscheit P, et al: Detection of smuggled cocaine in
cargo using MDCT. Am J Roentgenol 190:1390-1395, 2008
60. Leschka S, Fornaro J, Laberke P, et al: Differentiation of cocaine from
heroine body packs by computed tomography: Impact of different tube
voltages and the dual-energy index. J Forensic Radiol Imaging 1:46-50,
2013
61. Romano S, Romano L: Utilization patterns of multidetector computed
tomography in elective and emergency conditions: Indications, exposure
risk, and diagnostic gain. Semin Ultrasound CT MR 31:53-56, 2010
62. Tsapaki V, Rehani M, Saini S: Radiation safety in abdominal computed
tomography. Semin Ultrasound CT MR 31:29-38, 2010
63. Cahir JG, Freeman AH, Courtney HM, et al: Multislice CT of the
abdomen. Br J Radiol 77:S64-S73, 2004
64. Dawson P: Patient dose in multislice CT: Why is it increasing and does it
matter? Br J Radiol 77:S10-S13, 2004
65. Mandava N, Chang RS, Wang JH, et al: Establishment of a definitive
protocol for the diagnosis and management of body packers (drug mules).
Emerg Med J 28:98-101, 2011
66. Maurer MH, Niehues SM, Schnapauff D, et al: Low-dose computed
tomography to detect body-packing in an animal model. Eur J Radiol
78:302-306, 2011
67. Meijer R, Bots ML: Detection of drug containers by ultrasound scanning:
An airport screening tool? Eur Radiol 13:1312-1315, 2003
68. Chung CH, Fung WT: Detection of gastric drug packet by ultrasound
scanning. Eur J Emerg Med 13:302-303, 2006
69. Horrocks A: Abdominal radiography in suspected body packers. Clin
Radiol 45:322-325, 1992
70. Hierholzer J, Tantow H, Cordes M: X-ray detection of intracorporeal
smugglers: Radiologic and legal considerations. Akt Radiol 5:157-160,
1995
71. Beck J, Hale J: Cocaine body packers. Br J Surg 80:1513-1516, 1993
72. Grassi R, Di Mizio R, Pinto A, et al: Sixty-one consecutive patients with
gastrointestinal perforation: Comparison of conventional radiology, ultra-
sonography, and computerized tomography, in terms of the timing of the
study. Radiol Med 91:747-755, 1996
73. Catalano O, Grassi R, Rotondo A: Diagnosis of free air in the abdomen.
Role of echography. Radiol Med 87:632-635, 1994
74. DiMizioR,GrassiR,MarcheseE,etal:“Uncompensated”small bowel
obstructioninadults.Ultrasonographicfindings of free fluid between
loops and its prognostic value. Radiol Med 89:787-791, 1995
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