DESCRIPTION

"Body packer" refers to the intentional transport of narcotics or contraband inside a body cavity, usually the gastrointestinal tract, specifically to elude detection by law enforcement authorities.

• Typically, the material is well-packaged for gastrointestinal transit in multiple layers of latex, condoms, or tape.
• If leaking occurs, toxic effects may be delayed from hours to days and are more likely to be life threatening than the effects experienced by a body stuffer.
• Package contents can include heroin, cocaine paste or powder, crack cocaine, hashish, marijuana, marijuana oil, 3,4-methylenedioxymethamphetamine (MDMA; "ecstacy"), or amphetamines.
• Body sites include the gastrointestinal tract, vagina, ears, and rectum (antegrade route).
• The number of packages varies, but can exceed 200; each package can contain 3 to 30 g of drug, and the total drug weight may exceed 1 kg.
• The individual may use anticholinergic agents to decrease gastrointestinal motility.

"Body stuffer" refers to impulsive drug ingestion to evade prosecution by "swallowing the evidence" or by concealing the drugs in the vagina or rectum.

• Due to time pressure, the drug(s) are usually unwrapped or wrapped poorly in plastic, cellophane, balloons, paper, or foil.
• Packages are likely to leak, and symptoms are generally milder and develop earlier than with body packers.
• Ingestion of large quantities of drug is unusual.

PATHOPHYSIOLOGY

• Direct toxic effects of the ingested drug or adulterant may develop if the package leaks.
• Mechanical bowel obstruction may occur, particularly in the body packer.
• Local trauma to the esophagus, gastrointestinal tract, vagina, or rectum may occur during insertion.

EPIDEMIOLOGY

• Body stuffing is common; its toxic effects are common, but severe effects are rare.
• Body packing is uncommon; its toxic effects are uncommon but severe when they develop.

RISK FACTORS

• Body packing should be suspected in cases of recent international travel or incarceration.
• Body stuffing should be suspected in cases of recent arrest or witnessed ingestion by law enforcement authorities.

Section Outline:

• DESCRIPTION
• PATHOPHYSIOLOGY
• EPIDEMIOLOGY
• RISK FACTORS

DIFFERENTIAL DIAGNOSIS

Common Toxicologic Causes

• Body Packer. Heroin, cocaine paste or powder, or crack cocaine
• Body Stuffer. Any drug of abuse

Uncommon Toxicologic Causes

• Body Packer. Marijuana, hashish, marijuana oil, MDMA, or amphetamines
• Body Stuffer. Adulterants in drugs of abuse, including caffeine, lidocaine, procaine, ephedrine, strychnine, or quinine

Other Causes

• Bezoars, surgical abdomen, and constipation may mimic obstructive symptoms, and bowel ischemia may cause similar effects.
• Psychosis, infection, meningitis, hyperthyroidism, and pheochromocytoma may mimic sympathomimetic excess.

SIGNS AND SYMPTOMS

• Symptoms are determined by the ingested drug.
• Toxicity may develop rapidly if packets rupture.
• Rupture of packet should be suspected in a patient with abrupt deterioration.
• Abdominal pain or vomiting suggests obstruction or perforation.

Vital Signs

• Sympathomimetic drugs may cause tachycardia, hypertension, and hyperthermia, followed by cardiovascular collapse.
• Bradypnea and hypothermia may indicate opioid toxicity.

HEENT

• Dilated pupils indicate sympathomimetic ingestion or effects of anticholinergic drugs.
• Pinpoint pupils indicate opioid ingestion.
• Drooling or subcutaneous air suggests esophageal obstruction or perforation.

Cardiovascular

• Tachycardia and palpitations suggest cocaine or amphetamine effects.
• Bradycardia suggests opioid ingestion.
• Dysrhythmia or hypotension in body packer suggests that a life-threatening overdose is developing.
• Myocardial infarction, aortic dissection, bowel ischemia, and arterial spasm may occur.

Pulmonary

• Pulmonary edema may develop with heroin ingestion.
• Respiratory depression suggests opioid ingestion.

Gastrointestinal

• Abdominal tenderness or palpable mass may indicate obstruction, perforation, or abscess.
• Decreased bowel sounds indicate ileus due to anticholinergic drugs, opioids, or mechanical obstruction.

Hepatic

Severely hyperthermic patients may develop hepatic necrosis.

Renal

Acute renal failure may follow rhabdomyolysis, seizures, or hypotension.

Musculoskeletal

Rhabdomyolysis may develop in patients with seizures or hyperthermia.

Neurologic

• Seizures or stupor indicate significant toxicity in body stuffers and impending lethal deterioration in body packers.
• Agitation suggests sympathomimetic drug effects.
• Cerebrovascular accident may occur in severe overdose of sympathomimetics.

Psychiatric/Psychological

Hallucinations and paranoid behavior may indicate stimulants.

PROCEDURES AND LABORATORY TESTS

Testing is directed largely by the history and circumstances of presentation.

Essential Tests

• Body Stuffer. No tests may be needed in asymptomatic patients.
• Body Packer. Urine screen is used for drugs of abuse; a positive urine test result for drugs of abuse on presentation correlates well with the presence of drug packets in a body packer, regardless of findings on abdominal films. It is less useful to assess the course of evacuation of packets for body packers.

Recommended Tests

• ECG is used in symptomatic or tachycardic patients.
  • Tachycardia is common in mild sympathomimetic intoxication.
  • Other dysrhythmias suggest severe overdose.
• Arterial blood gases or pulse oximetry is used in cases involving bradypnea, hypoxia, or hypoventilation.
• Serum electrolytes, BUN, and creatinine should be measured in symptomatic patients; metabolic acidosis or renal injury suggests serious intoxication.

Imaging for Body Stuffer

• Abdominal radiograph is generally not indicated, unless mechanical obstruction is suspected.
• Transabdominal ultrasonography may be useful for noninvasive vaginal evaluation.
• Chest radiography is used in patients with pulmonary symptoms.

Imaging for Body Packers

• Abdominal radiography is diagnostic in 70% to 90% of cases.
• A falsely positive abdominal radiograph may occur due to constipation.
• Water-soluble contrast may increase sensitivity of abdominal films but requires a several hour delay. It is useful for evaluating complete passage of packets and mildly promotes gastrointestinal motility.
• CT scan may be indicated for a case with a negative abdominal series but a high suspicion of ingestion.
• Ultrasonography is useful for noninvasive vaginal evaluation, but does not improve detection of abdominal packages.

Section Outline:

• DIFFERENTIAL DIAGNOSIS
  • Common Toxicologic Causes
  • Uncommon Toxicologic Causes
  • Other Causes
• SIGNS AND SYMPTOMS
  • Vital Signs
  • HEENT
  • Cardiovascular
  • Pulmonary
  • Gastrointestinal
  • Hepatic
  • Renal
  • Musculoskeletal
  • Neurologic
  • Psychiatric/Psychological
• PROCEDURES AND LABORATORY TESTS
  • Essential Tests
  • Recommended Tests
  • Imaging for Body Stuffer
  • Imaging for Body Packers

• Supportive care with appropriate airway management is vital; specific treatment is initiated while supportive care continues.
• Dose and time of exposure should be determined for all substances involved.
• Emergent surgical consultation is indicated for symptomatic body packers or stuffers.

DIRECTING PATIENT COURSE

The health-care provider should call the poison control center when:

• hypoxia, seizures or other serious effects are present.
• coingestant, drug interaction, or underlying disease presents an unusual problem.

The patient should be referred to a health-care facility if a history of body packing or stuffing is obtained.

Admission Considerations

• Patients who are suspected body packers should be admitted to complete decontamination, which often requires several hours.
• Body stuffers should be admitted if persistent toxic effects develop.

DECONTAMINATION

• Do not induce emesis due to the risk of rupturing a drug packet and potential for aspiration or esophageal obstruction.
• Gastric lavage or manual removal of packets are not recommended due to the potential for rupture.
• One dose of activated charcoal (1-2 g/kg) should be administered if a substantial ingestion has occurred within the previous few hours.
• Whole bowel irrigation is recommended for body stuffers or packers.
  • 2 L/h of polyethylene glycol solution should be administered until passage of two packet-free stools.
  • Water-soluble contrast abdominal series is useful for evaluating complete passage of packets in body packer.
  • Gastrointestinal decontamination may require several days of close observation.

ANTIDOTES

Naloxone is used for opioid toxicity.

• Indication. Respiratory depression
• Contraindications. Documented naloxone allergy
• Method of administration
  • Naloxone is administered as a 2.0-mg intravenous push, and the response should be observed.
  • If no response, the dose is repeated in 2.0-mg increments to a total dose of 10 mg.
  • Although less desirable, naloxone also may be administered by endotracheal, intramuscular, intralingual, intraosseous, or subcutaneous injection.
• Patients with persistent or recurrent effects may be treated with constant infusion of naloxone.

ADJUNCTIVE TREATMENT

• Respiratory depression. Endotracheal intubation is used for patients with respiratory depression who do not respond to naloxone.
  • Body packers should be intubated early if toxic effects develop due to high risk of lethal overdose.
  • Intravenous access, cardiac monitoring, and oxygen administration should be performed on all patients.
• Hyperthermia. Aggressive cooling measures are used for hyperthermic patients.
• The endoscopic removal of drug packages is contraindicated due to the risk of rupture.

Section Outline:

• DIRECTING PATIENT COURSE
  • Admission Considerations
• DECONTAMINATION
• ANTIDOTES
• ADJUNCTIVE TREATMENT

• Body stuffers usually manifest toxicity early and then recover rapidly with appropriate treatment.
• Body packers usually manifest toxicity days after ingestion and afterward have a stormy medical course with serious toxicity from whatever drug was used.

The health-care professional should consider adulterants used to manufacture or dilute the drug.

TREATMENT

Early endotracheal intubation should be performed immediately in a deteriorating body packer.

Poisoning by analgesics, antipyretics, and antirheumatics: opiates and related narcotics.

See Also: SECTION III, Naloxone and Nalmephene and Whole Bowel Irrigation chapters; and SECTION IV, Cocaine chapter.

RECOMMENDED READING

McCarron M. The cocaine "body packer" syndrome. JAMA 1983;250:1417-1420.

Sporer KA. Clinical course of crack cocaine body stuffers. Ann Emerg Med 1997;29:596-601.

Utrecht MJ. Heroin body packers. J Emerg Med 1993;11:33-40.

Author: Michael Stackpool

Reviewer: Katherine M. Hurlbut