Bowel obstruction in body-packing: A case report and literature review

Abstract

Introduction and importance

The body packer swallows or embeds drugs in body cavities in a purposeful way. Packets usually contain of opium, cocaine, cannabis and amphetamines. The significant complications of body packing usually are symptoms of drug toxicity due to leaking or ruptured packets or symptoms of ingesting relatively large foreign bodies. Herein, we present a case of heroin body-packing that resulted in subsequent bowel obstruction.

Case presentation

A 30-year-old male, who was brought from the prison to the emergency department, complained of abdominal pain. After the absence of intoxication symptoms and insignificant plain abdominal radiograph results, abdominal computed tomography (CT) scan revealed the presence of ingested packets in the stomach as well as in the patient's small intestine. Therefore, the decision of surgery was immediately made for the patient, and during the surgery, the drug packets were entirely removed. The patient was discharged in good general condition three days after his surgery.

Clinical discussion

Body packers are in considerable risk as rupture of packet inside the body and risk of obstruction that both of them may be fatal. Patients should be monitored for complications, possible early treatment, and removal or assistance in expulsion drug packets from the body. Initially on plain abdominal radiographs, classic findings suggest the presence of drug packets.

Conclusion

In case of an inconclusive plain abdominal radiograph, further investigation with CT is indicated, with an almost 100 % sensitivity. For symptomatic patients, bowel obstruction and acute drug toxicity are the two most common indications for surgical intervention.

Highlights

• •Body packing is an often neglected cause of mechanical bowel obstruction.
• •Patients with body packer syndrome initially present with insidious symptoms.
• •In cases with high suspicion, objective clinical and imaging data should be prioritized.

1. Introduction

Body packing has been recognized as a method of drug smuggling for over four decades. It differs from body stuffing, where individuals hastily swallow drugs in response to the imminent risk of arrest. In contrast, body packers employ a purposeful approach, either swallowing or embedding drugs in body cavities such as the vagina, intestines, and ears (1,2).

Body packers have the capacity to carry approximately 1 kg of drugs, which is often divided into multiple packets (3). These packets are packaged using a variety of materials and shapes, including condoms, plastic bags, capsules, latex gloves, or balloons. The specific choice of packaging depends on the local drug market and the border-crossing requirements (3,4). The packets typically contain a range of substances such as heroin, cocaine, opium, cannabis, amphetamines, and methamphetamine derivatives (3,4). Among these drugs, heroin, also known as diacetylmorphine, is one of the most commonly smuggled substances by body packers (5). Heroin is a synthetic derivative of the morphine alkaloid found in opium and is known to be approximately twice as potent as morphine (6).

Most significant medical complications of body packing usually are signs and symptoms of drug toxicity due to leaking or ruptured packets and symptoms of ingesting relatively large foreign bodies like gastrointestinal obstruction or perforations (7).

2. Case presentation

A 30-year-old male prisoner was transferred from the prison to the emergency department due to a complaint of abdominal pain persisting for approximately three days. The patient also reported experiencing nausea and vomiting, while his bowel movements remained normal. Upon examination, the patient exhibited full orientation and consciousness, with a Glasgow Coma Scale score of 15/15. Vital signs, including blood pressure (110/70 mmHg), heart rate (approximately 80 beats per minute), respiratory rate (15 per minute), and body temperature, were within normal ranges. Neurological, cardiopulmonary, and digital rectal examinations revealed no abnormalities, and there were no signs of drug overdose or intoxication. Laboratory results from initial workup assays (Complete blood count, C-reactive protein, Erythrocyte sedimentation rate, Creatinine, Blood urea nitrogen, Liver function tests, Amylase, Lipase, and Coagulation profile) was only significant for a mildly elevated leukocyte count (WBC) of 12.0 (10⁹ cells/L) on the day of admission.

A plain abdominal radiograph was inconclusive, yielding no significant findings. To further investigate the patient's condition, a computed tomography (CT) scan was performed, which revealed the presence of foreign bodies (drug packs) in both the stomach and small intestine (Fig. 1). Subsequently, the decision was made to proceed with emergent surgical intervention. The patient underwent laparotomy, gastrotomy, and enterotomy. The duration of the intraoperative procedure was approximately 2 h. A total of 13 drug packets were successfully extracted from the patient, with each packet weighing 45 g. None of the drug packets were found to be ruptured (Fig. 2). Following the surgery, the patient was transferred from the postoperative intensive care unit on day 3 with no specific complications observed. The successful removal of the drug packets led to an improvement in the patient's overall condition, and the patient was subsequently discharged from the hospital after three days. The recovery continued to progress favorably with no complaints in the follow-up visit 3 months after the surgery. This case report study was conducted in accordance with the SCARE 2020 guidelines (8).

Fig. 1.

Packs in the stomach and small intestine.

Fig. 2.

Intraoperative photographs and drug packets extracted from the patients.

3. Discussion

In this case report, we highlight the consequences of heroin body packing, which resulted in bowel obstruction and required surgical intervention for resolution. Body packers, also known by various terms such as “swallowers,” “internal carriers,” or “mules,” play a significant role in the global drug smuggling landscape. They employ the method of carefully packaging illicit drugs into pellets or packets and then ingesting or inserting them into body cavities, primarily within the gastrointestinal tract, with the intention of evading detection during transportation across borders (9).

The term “body packing” was officially coined in 1973, but there are anecdotal reports predating its recognition in the medical literature, describing similar incidents that align with the concept of body packing, dating back a decade earlier (10).

Body stuffing as opposed to body packing is a distinct clinical entity. The difference was first acknowledged by Robert, et al. in 1985 (11,12). Body stuffing refers to the hasty ingestion of loosely wrapped packages of illicit drugs in fear of arrest, often presenting with an acute clinical picture as a result of rupture of the poorly packet drug packets and drug leakage (11,13).

In this case, the patient exhibited symptoms consistent with bowel obstruction and was within the prison system. Due to the legal repercussions associated with internally concealing illicit drugs for smuggling purposes, the reliability of the patient's reported history was uncertain. Thus, distinguishing between body stuffing and body packing remained challenging. However, considering the clinical presentation, along with the findings from physical and clinical examinations, the patient was suspected to be a “body packer.” Throughout the entire diagnostic and treatment process, a high level of clinical suspicion was maintained to ensure appropriate management.

Persistent and consecutive history taking by medical staff led to the suspicion that the ingested packets were containing Diacetylmorphine (Heroin), which was confirmed by subsequent laboratory analysis after surgical extraction. Diacetylmorphine is among the most common drugs retrieved from body packers worldwide (9,14). When illicit drugs are concealed intracorporeally by body packers, it exposes them to the risk of life-threatening conditions such as drug overdose, toxicity from ruptured packets, and gastrointestinal obstruction. Drug toxicity secondary to opioid drugs like Diacetylmorphine may present with diminished mental status, decreased respiratory effort and subsequent arrest, contracted pupils, and decreased bowel sounds, while drug poisoning due to cocaine and stimulants may lead to mydriasis, hypertension, agitation and altered mental status, diaphoresis, and tachycardia.

These complications pose significant dangers to body packers' health and well-being. Unfortunately, due to the fear of legal consequences and potential legal indictment, body packers often hesitate to seek medical attention until critical symptoms have developed. This delay in seeking timely medical care further exacerbates the risks and challenges associated with their condition.

Imaging is the preferred diagnostic tool with regards to obstruction. Plain abdominal radiography is usually the first method used in the evaluation and diagnosis of body packers, but with a wide range of accuracy in light of a number of factors including varying packing methods in addition to more sophisticated methods in recent years, and masking skills of the smugglers (15). Initially on plain abdominal radiographs, generally well-known appearances such as “parallelism sign,” “Rosette sign,” “double-condom sign” and “tic-tac sign” are classic findings that suggest the presence of drug packets. In the case of an inconclusive plain abdominal radiograph, further investigation with CT is indicated, with a sensitivity of almost 100 % (16,17). Even though CT is not the preferred screening method in body packers, CT scout views have been found to be superior to conventional radiography in detection of drug packets at a significantly lower radiation dose. This is especially important in the context of asymptomatic body packing suspects in case of which after negative findings on conventional radiography, there will be no clinical indication for a subsequent CT despite remaining suspicion (18).

Asymptomatic body packers are attended to with a conservative approach by most hospitals. As for symptomatic patients, bowel obstruction and acute drug toxicity are the two most common indications for surgical intervention. However, based on the clinical approach provided by Yegane et al., it is recommended that patients with symptoms of toxicity be preferably managed by their pharmacological or physiological antagonists and then proceed with observation or laparatomy based on signs of obstruction, persistent toxicity or package retention after 5 days (19). Surgical approaches and recommendations vary between clinical centers and with anatomical location. For intenstinal retention single enterotomy or enterotomy and milking is recommended while gastrotomy is the method of choice for gastric retention. Generally, colotomy is not recommended for cases with colorectal retention, with milking and transanal evacuation or colonoscopy/rectosigmoidoscopy being prioritized over surgical incision (20).

Furthermore, in another study in 2016, conservative treatment with PEG and bowel irrigation, with surgery considered only in cases showing signs of gastrointestinal obstruction and/or drug toxicity, yielded good results (14). Nonetheless, surgery is still the preferred method of management in cases of prolonged retention of drug packets with no to little response to medical therapy (20).

In conclusion, even though the patient admitted to our care recovered without complications, documenting this case along with similar cases enable health care professionals to have better insight into similar scenarios to help with making precise and timely decisions. Moreover, authorities can further utilize different patterns of presentation discussed to suspect and detect cases of body packing in prisons and other common settings in an early stage, to help prevent complications and allow for conservative management.

Ethical approval

This case study was exempt from ethical approval as informed consert was obtained directly from the patient. Ethical approval was waived by Ethics Committee at Alborz University of Medical Sciences.

Funding

The authors did not receive any external support or funding for the preparation of this work.

Guarantor

Dr. Javad Zebarjadi accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

Research registration number

Dear Editor, regarding your request to register the study, you should consider that the current case study is not a “First in Man” study as you have described in the author disclosure form. As such, we believe that it is exempt from registry.

Furthermore, the authors' country of residence is restricted due to economic sanctions and we have significant difficulty in procuring and transferring the required funds for registering the study. The authors also do not have access to other free registries such as clinicaltrials.gov.

CRediT authorship contribution statement

Behzad Nemati Honar: Conceptualization, Project administration, Supervision, Writing – review & editing. Ghazale Mollaverdi: Writing – original draft, Data curation. Javad Zebarjadi Bagherpour: Data curation, Writing – review & editing, Supervision.

Conflict of interest statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.