Apple, condom, and cocaine - Body stuffing in prison: A case report

Abstract

Background:
Drug dealers and drug users resort to body stuffing to hastily conceal illicit drugs by ingesting their drug packets. This practice represents a medical challenge because rupture of the often insecure packaging can be toxic and even lethal. In an emergency setting, official guidelines are needed to help the medical team decide on the proper treatment. A preliminary observation period is generally accepted but its duration varies from hours to eventual packet expulsion.

Case presentation:
This case involves a 20-year-old white man in detention who claimed to have ingested one cocaine packet wrapped in plastic food-wrap and a condom in anticipation of an impending cell search. He reached out to medical professionals on day 4 after having unsuccessfully tried several methods to expel the drug packet, including swallowing olive oil, natural laxatives, liters of water, and 12 carved apple chunks. An initial computed tomography scan confirmed multiple packet-sized images throughout his stomach and bowel. After 24 hours of observation and normal bowel movements without expelling any packets, a subsequent scan found only one air-lined packet afloat in the gastric content. Due to the prolonged retention of the package there was an increased risk of rupture. The packet was eventually removed by laparoscopic gastrotomy.

Conclusions:
This case report illustrates that observation time needs to be adapted to each individual case of body stuffing. Proof of complete drug package evacuation ensures secure patient discharge. Body stuffers should be routinely asked for a detailed history, including how the drug is wrapped, and whether or not they ingested other substances to help expel the packets. The history enables the accurate interpretation of imaging. Repeated imaging can help follow the progress of packets if not all have been expelled during the observation period. Drug packets should be surgically removed in case of prolonged retention. To ensure the best possible outcomes, patients should have access to high-quality, private, and confidential medical care, which is equal to that offered to the general population. This is paramount to earning trust and collaboration from people in detention who resort to body stuffing.

Full text

C A S E R E P O R T Open Access
Apple, condom, and cocaine –body
stuffing in prison: a case report
Benedicte Jalbert
1†
, Nguyen Toan Tran
2*†
, Stephan von Düring
1
, Pierre-Alexandre Poletti
3
, Ian Fournier
4
,
Catherine Hafner
1
, Celestine Dubost
2
, Laurent Gétaz
2
and Hans Wolff
2
Abstract
Background: Drug dealers and drug users resort to body stuffing to hastily conceal illicit drugs by ingesting their
drug packets. This practice represents a medical challenge because rupture of the often insecure packaging can be
toxic and even lethal. In an emergency setting, official guidelines are needed to help the medical team decide on
the proper treatment. A preliminary observation period is generally accepted but its duration varies from hours to
eventual packet expulsion.
Case presentation: This case involves a 20-year-old white man in detention who claimed to have ingested one
cocainepacketwrappedinplasticfood-wrapandacondominanticipationofanimpendingcellsearch.Hereachedout
to medical professionals on day 4 after having unsuccessfully tried several methods to expel the drug packet, including
swallowing olive oil, natural laxatives, liters of water, and 12 carved apple chunks. An initial computed tomography scan
confirmed multiple packet-sized images throughout his stomach and bowel. After 24 hours of observation and normal
bowel movements without expelling any packets, a subsequent scan found only one air-lined packet afloat in the gastric
content. Due to the prolonged retention of the package there was an increased risk of rupture. The packet was eventually
removed by laparoscopic gastrotomy.
Conclusions: This case report illustrates that observation time needs to be adapted to each individual case of body
stuffing. Proof of complete drug package evacuation ensures secure patient discharge. Body stuffers should be routinely
asked for a detailed history, including how the drug is wrapped, and whether or not they ingested other substances to
help expel the packets. The history enables the accurate interpretation of imaging. Repeated imaging can help follow the
progress of packets if not all have been expelled during the observation period. Drug packets should be
surgically removed in case of prolonged retention. To ensure the best possible outcomes, patients should
have access to high-quality, private, and confidential medical care, which is equal to that offered to the general
population. This is paramount to earning trust and collaboration from people in detention who resort to body stuffing.
Keywords: Body stuffing, Prison, Cocaine, Condom, Apple, Gastric retention, Radiology pitfalls
Background
Body stuffers, who are at the end of the drug trafficking
chain as community drug dealers or consumers, swallow
the few drug packets that they have on hand (mostly
cocaine and heroin) to conceal them from law enforce-
ment in anticipation of impending searches or arrest [1].
In contrast, body packers usually ingest a large number
of mechanically manufactured compact drug packets
enclosed in multiple layers of wrapping to resist rupture
during long-distance drug smuggling [2].
When taken to a medical facility, an unenhanced com-
puted tomography (CT) scan is usually preformed and is
preferred to conventional X-ray for confirmation of the
diagnosis [3–5]. Body stuffers are then usually observed
for a few hours and released if no complications occur
[6]. However, the required duration of the observation is
still debated with some authors recommending
discharge after 6 hours of unremarkable observation,
and others recommending a conservative approach,
which consists of waiting for the evacuation of the drug
packets by unaided bowel movements (no medication,
* Correspondence: Nguyen-Toan.Tran@hcuge.ch
†
Equal contributors
2
Division of Prison Health, Geneva University Hospitals and Faculty of
Medicine, University of Geneva, Geneva, Switzerland
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Jalbert et al. Journal of Medical Case Reports (2018) 12:35
DOI 10.1186/s13256-018-1572-8
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

such as prokinetic agents or laxatives) [7,8]. The use of
oil-based laxatives is not recommended as it can cause
packet rupture due to a chemical reaction with latex [9].
However, if patients do not spontaneously expel the
packets after a few days, especially if these were loosely
wrapped and not intended for internal concealment,
they will require further medical attention due to the in-
creased risk of rupture. This is true even if reported
body stuffer fatalities are rare and the quantity of
ingested drugs is usually less than that of body packers
[10–12]. However, packet rupture is dangerous and can
be lethal [13,14]. Surgery is the recommended choice to
safely remove retained drug packets versus endoscopy in
which the manipulation of packets increases the risk of
rupture [15–17].
We present this case report to shed light on some of
the particular and confusing circumstances that can be
found when managing body stuffers. Our report demon-
strates that a 6-hour observation period can be insuffi-
cient and that CT findings must be correlated with the
patient’s story in order to determine the severity of the
situation.
Case presentation
This case involves a 20-year-old healthy white man in-
carcerated in a detention center in Geneva, Switzerland.
He had no medical or mental health conditions and did
not take any medication. He has two older siblings, had
dropped out of school at a young age, and was living
with his mother at the time of incarceration. He used to
smoke tobacco and cannabis, which he stopped 2 years
ago, consumed cocaine and ecstasy (methylene-dioxy-
methamphetamine) until 6 months before his incarcer-
ation, and drank alcohol occasionally without reporting
any binge drinking. Due to a recent trauma to his left
wrist, he was accompanied to our University Hospital
for an X-ray. Once in Radiology, he confessed to the
technician that he had ingested an illicit drug packet 4
days earlier in anticipation of an impending cell search.
The drug packet was reportedly 4 to 5 cm in size, con-
tained 6 to 8 g of cocaine, and was wrapped in a condom
and plastic food-wrap. He was worried because he had
not yet evacuated the packet and had been experiencing
mild epigastric pain for a few hours before his x-ray
appointment. He did not have any other gastrointestinal
(GI) symptoms, including nausea, vomiting, diarrhea,
and constipation. After the wrist X-ray he was taken to
our Emergency Department (ED) for the management of
the body stuffing. On admission, his vital signs were as
follows: blood pressure of 131/60 mmHg, heart rate of
74 beats/minute, and temperature of 37.6 °C. He was
alert, oriented, calm, and expressed no intention of self-
harm. A physical examination revealed epigastric tender-
ness, but no abdominal rigidity, guarding, rebound
tenderness, or evidence of a palpable mass. The rest of
the examination was unremarkable, including a cardio-
pulmonary and a complete neurological examination.
Laboratory findings were within normal range, including
a complete blood count (hemoglobin of 16.2 g/dL, white
cell count of 8.5 G/L, platelet count of 121 G/L), kidney
and liver function tests, and a urine analysis. Tests for
HIV and hepatitis B were negative. He returned to our
Radiology Department where a low-dose abdominal CT
scan was performed and revealed multiple foreign bodies
of similar aspect throughout his stomach, his duodenum,
and his small intestine, all of which were consistent with
packets of loosely aggregated drugs (Fig. 1a). There was
no sign of GI perforation or obstruction.
He was subsequently admitted to our in-patient
Carceral Unit for observation. When confronted with
the radiology findings of multiple foreign bodies he
Fig. 1 aMultiple intradigestive foreign bodies (arrows) situated in the
stomach, the duodenum, and small intestine on computed tomography
(coronal view). bSingle heterogeneous foreign body (arrow)containing
air measuring 3.1 × 3.2 × 4 cm located in the stomach on computed
tomography (axial view)
Jalbert et al. Journal of Medical Case Reports (2018) 12:35 Page 2 of 5
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insisted on having swallowed only one drug packet.
Further exploration revealed that he used various GI-sti-
mulating techniques which had been recommended by
his fellow inmates to accelerate the expulsion of his
slow-progressing packet. These included drinking large
quantities of water (more than 3 L daily), ingesting three
to four tablespoons of olive oil daily, a cupful of natural
fig-based laxative, and applying warm towels on his
“liver.”On day 3 after the packet ingestion and as a last
resort, he carved and ingested 12 bite-sized apple
chunks with the hope that together they would push the
packet through his GI system. Despite all these attempts,
he continued to have regular bowel movements once
daily without evacuating the packet. The fear of a
complication compelled him to seize the opportunity of
being brought to the X-ray room to reveal the circum-
stances of his condition to the radiology technician.
Since the apple chunks could have been interpreted as
images of loosely compacted drug packets, a second
low-dose CT scan was performed the day after his ad-
mission (day 5 post-ingestion): the apple chunks were
partially digested and the images showed the persistence
in his stomach of one foreign body containing air and
measuring 3.1 × 3.2 × 4 cm (Fig. 1b).
Since the packet had been trapped in his stomach for
the past 5 days, the condom wrapping was likely to have
been compromised by gastric acidity, thus increasing the
risk of rupture. Therefore, a proton pump inhibitor
(PPI) of esomeprazole was administered intravenously.
After discussing management options with our patient,
GI specialists recommended using surgery rather than
gastric endoscopy in order to extract the drug packet
with a minimum of risk. A laparoscopic gastrotomy
confirmed a floating packet in the gastric fluid which
was removed without complications (Fig. 2). Analysis of
the packet after retrieval confirmed that the drug was
cocaine. The packet was loosely wrapped in two differ-
ent materials: a first double layer of plastic food-wrap
inserted into a condom which was tied with a knot and
folded back to form another layer and secured with an
outer knot (Figs. 3and 4).
He presented a transitory fever up to 38.8 °C at
48-hours post-surgery but otherwise maintained normal
vital signs. He resumed oral intake shortly after surgery
and continued the PPI treatment for 2 weeks after
surgery to aid healing. He was discharged back to prison
on day 4 post-surgery. An out-patient follow-up in the
prison health service was unremarkable. He was released
from detention 2 months after surgery and further
follow-up was not possible.
Discussion
This is the case of a 20-year-old man who ingested apple
chunks to help with the expulsion of a cocaine packet,
which was eventually removed by laparoscopic gastrot-
omy. It illustrates several points that are necessary to
consider for the management of body stuffers.
First, contrary to the recommendations of Yamamoto
et al., an adequate observation time in a medical setting
is necessary even if body stuffers do not show signs of
complication during the first 6 hours following packet
ingestion [7]. Body stuffers often resort to precarious
packaging for hasty concealment. Therefore, care must
be organized around this point. They present an
increased risk of packet rupture and unpredictable pro-
gression through the digestive system resulting in the
possibility of delayed toxicity even if no signs of toxicity
are observed within the first 6 hours post-ingestion. This
Fig. 2 Gastrotomy by laparoscopy showing the packet floating in
the stomach (blue arrow)
Fig. 3 Drug packet tied in a condom with an internal knot (white arrow);
the second layer of the condom which was folded back to form another
protective layer and tied with an outer knot (blue arrow)wascutopen
and pulled to the left (yellow arrow)
Jalbert et al. Journal of Medical Case Reports (2018) 12:35 Page 3 of 5
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

case shows that loosely aggregated drugs within a poorly
wrapped package with trapped air between the different
layers may not have the sufficient density to descend
and engage into the pylorus. This is compounded if the
patient drinks large amounts of fluids which may facili-
tate normal transit but will keep the packet buoyant in
the stomach. A premature discharge of our patient from
the hospital could have resulted in poor outcomes and
even death (the estimated weight of 6 to 8 g of cocaine,
even with admixture, surpasses the minimum lethal dose
of 1.2 g of pure cocaine) [10]. Until now, no official
guidelines have been set to determine the correct
duration of surveillance of body stuffers. Therefore, we
believe that it is essential to incorporate the influence of
these different technical parameters into the duration of
the observation time and discuss with the patient the
risks and benefits of a prolonged surveillance to deter-
mine the most appropriate course of action.
Second, localizing the number, location, and progres-
sion of packets is necessary for clinical management.
The detection of internal drug packets must be per-
formed by low-dose CT without contrast rather than by
conventional X-ray as CT is superior in providing an ac-
curate and reliable detection of different densities, from
low-density to high-density packets and different dens-
ities of drug aggregation [18]. However, there can be
pitfalls due to foreign bodies of similar density, especially
if located in the stomach, which can mimic the images
of drug packets, as was the case with the pieces of apple
in our case study. The literature reports other swallowed
foreign bodies that can resemble drug packets, including
scybala (hardened masses of feces), grains, stones, or
fruits [19]. A way to differentiate the nature of the in-
gesta would be to measure the Hounsfield unit on CT,
which reflects density. However, density measurements
are not completely reliable as the nature of the
substance, such as its purity, admixture, and compres-
sion, plays a major role in imaging [18]. Therefore, body
stuffers should be routinely asked whether they ingested
other substances to help expel the packages and their
history should help interpret the CT images.
Third, latex wrapping warrants some attention. Latex
condoms can be used for packaging drugs in body stuff-
ing and less rarely in body packing, where packages are
generally manufactured mechanically to ensure robust-
ness. It is well documented that oil-based lubricants
have an adverse effect on the physical properties of latex
condoms (tensile strength, break at elongation, burst
pressure, and volume), which can result in their rupture
[9]. Such lubricants are found in laxatives, which is the
reason their use is not routinely recommended for accel-
erating the evacuation of drug packets. Gastric juices are
extremely corrosive due to their acidity. Therefore,
neutralizing the acidity with a PPI appeared to be an em-
pirically safe way to delay the corrosion and rupture of a
condom-wrapped package trapped in the stomach.
However, surgical management in our case was the
safest option.
Fourth, body stuffers usually do not trust authorities
and are not prone to admitting their drug concealment
to anybody. Therefore, they are at increased risk of
complications, even more so if they are already in deten-
tion. The Geneva University Hospitals have a long-held
tradition of providing health services in the detention
centers in the canton of Geneva. These services are in-
dependent of the judiciary and prison system and are
guided by a human rights-based approach to guarantee
free access to a health care provider, equivalence of care,
and patient’s consent and confidentiality [20]. The re-
spect of these principles gives confidence to people
living in detention toward health care professionals: it
enables them to seek help that they trust whenever
needed. In our case, the patient reached out to a radi-
ology technician (and not to a prison staff member), and
collaborated with the ED and in-patient medical team,
knowing that the circumstances of his medical interven-
tion would be known only to the medical team and
would not be divulged to the penal authorities.
Conclusions
This case report illustrates that sufficient observation
time in an appropriate medical setting is essential for
patients presenting with drug body stuffing. Complete
drug package evacuation ensures secure patient dis-
charge. A detailed history is fundamental in body
stuffers, including how the drug is wrapped, and whether
or not other substances were ingested to help expel the
packets. The history must be taken into account in the
careful interpretation of CT images, and imaging should
be repeated if the progression of the packets is in doubt.
Fig. 4 Unwrapped drug packet from a double layer of plastic food-wrap
with a positive cocaine identification (in blue)
Jalbert et al. Journal of Medical Case Reports (2018) 12:35 Page 4 of 5
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Drug packets should be surgically removed in case of
retention. To ensure the best possible outcomes, provid-
ing access to private, confidential, and high-quality med-
ical care, which is equal to the care offered to the
general population, is paramount to gain trust and
collaboration from people in detention who resort to
body stuffing.
Abbreviations
CT: Computed tomography; ED: Emergency Department; GI: Gastrointestinal;
PPI: Proton pump inhibitor
Acknowledgements
None.
Funding
No funding was received for this study.
Availability of data and materials
All data generated or analyzed during this study are included in this published
article.
Authors’contributions
BJ wrote the first draft of the manuscript. SVD, CH, CD, IF, and NTT were in
charge of clinical patient care. PP supervised and interpreted the radiological
examinations. NTT, SVD, LG, and HW reviewed the manuscript. All authors read
and approved the final manuscript.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Written informed consent was obtained from the patient for publication of this
case report and any accompanying images. A copy of the written consent is
available for review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Department of General Internal Medicine, Geneva University Hospitals and
Faculty of Medicine, University of Geneva, Geneva, Switzerland.
2
Division of
Prison Health, Geneva University Hospitals and Faculty of Medicine,
University of Geneva, Geneva, Switzerland.
3
Department of Radiology,
Geneva University Hospitals and Faculty of Medicine, University of Geneva,
Geneva, Switzerland.
4
Department of Visceral Surgery, Geneva University
Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
Received: 6 November 2017 Accepted: 12 January 2018
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