Body packers and stuffers

Introduction

• Body packers
  • Meticulous packing in most cases to allow transport across international borders
  • Up to 1kg of drug in up to 100 packets can be transported by a single individual
  • Use constipating agents such as atropine-diphenoxylate to slow GI transit
  • Ingested packets usually in intestine by the time of ED presentation
  • Present in acute drug intoxication or fear of impending rupture, request by authorities for medical assessment following arrest or bowel obstruction/perforation
• Body stuffers
  • Haphazard rushed internal concealment of poorly packaged drugs, often of different types and far more likely to leak
  • Delay from ingestion to ED presentation usually much shorter and frequently ingested packets are still in the stomach
  • Vagina and rectum often used

Management of body stuffers

• Observe and monitor with IV access
• If presents within 1 hour, a single dose of 50g AC is indicated
• Examine all orifices
• Non-con abdo CT can localise or exclude presence of packets
• Urine drug screens rarely alter management
• If asymptomatic on no packets on examination and abdo CT can be safely discharged

Management of body packers

• Resus
• Risk assessment
  • Onset of signs of drug intoxication may herald imminent catastrophic deterioration
  • Vital to know type of drug, number and construction of packages and time of ingestion
  • Examine for signs of intoxication and surgical complications
  • Admit to SSW or ICU for monitoring, IV access throughout and staff briefed on signs of intoxication
  • Continuous ECG and pulse oximetry when not ambulatory, esp. when asleep
  • Asymptomatic patients can eat a normal diet
  • Ambulation around ward is encouraged as bed rest is a risk factor for bowel obstruction
  • Observed until expected number of packets retrieved or three package-free stools passed and repeat abdominal CT is negative
  • Mean time to pass all packages is 5 days

Management of body packers

• Investigation
  • Urine toxicology has low sensitivity
  • Negative test does not exclude body packing or indicate safe for discharge
  • Non-con CT is the most sensitive Ix and is the Ix of choice (100% sens/spec/NPV/PPV)
  • Packet counts are accurate if <15 packets exist but if >15, correlation is poor
  • Once all packets passed, repeat CT to confirm all passed is mandatory

Management of body packers

• Decontamination
  • Cooperative asymptomatic patients can get 50g AC in case of leak/rupture
  • Incidence of serious complications such as late-onset drug intoxication, bowel obstruction, urgent laparotomy or death is <5% with conservative management
  • Light or liquid diet +- gentle laxatives are offered in order to speed passage
  • Whole bowel irrigation is controversial
    • Not indicated for heroin as good outcome expected even in the event of rupture with naloxone/supportive care
  • Endoscopy for packages in stomach too large to pass pylorus (carries risk of rupture though)
  • Colonoscopy considered if packages retained in colonic flexures (carries risk of rupture though)
  • If evidence of cocaine intoxication, resuscitate and urgent theatre for laparotomy/enterotomy and careful removal of all packages
  • If evidence of bowel obstruction or perforation – theatre for removal

Last Updated on October 14, 2020 by Andrew Crofton