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Three Part Question

In [asymptomatic patients who have swallowed packets of cocaine in order to smuggle them across borders] is [conservative management] effective at [preventing the morbidity and mortality associated with body-packing]?

Clinical Scenario

You are called to see a young adult male who is accompanied by two members of Her Majesty's Customs and Excise. They tell you that he is under suspicion of trying to smuggle drugs into the country and that he may have done this by ingesting packets of cocaine. Physical examination is unremarkable, but abdominal radiography does reveal multiple, oval foreign bodies in the bowel. You know that such 'body packers' might well develop intestinal obstruction and/or get potentially fatal cocaine toxicity from leakage of the contents of these packages in their bowels. You wonder whether to simply leave the patient as he is and observe him for signs of obstruction and/or pending cocaine toxicity, intervene conservatively and do the latter as well, or whether to do something more aggressive to remove the packages from the patient's intestines.

Search Strategy

Medline 1966-12/02 using the OVID interface.
[exp cocaine OR exp cocaine-related disorders OR exp crack cocaine or "cocaine".mp] AND [exp foreign bodies OR exp gastrointestinal system OR "packet".mp OR "INGESTED".mp] LIMIT to human AND English Language

Search Outcome

Altogether 171 papers found of which 111 were irrelevant and a further 55 papers were unsuitable for inclusion due to either having insufficient patient numbers to be useful (usually single/double case reports - range: 1-7 patients, n = 36 papers, including 5 letters/editorials), or for being irrelevant to the other core issue of how to actually manage cocaine packet ingestion (n = 19 papers - usually on only investigating body packing). In addition one more relevant paper not yet indexed on Medline was found. The four papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
McCarron MM and Wood JD, 1983, USA	48 suspected smugglers with ingested intra-corporeal cocaine packets (number of packets per patient 15-175)	Prospective cohort	Complete passage of packets per rectum	47 patients
			Emergency surgery	1 patient with obstruction
			Complications of conservative management	2 patients developed cocaine toxicity due to packet
Caruana DS et al, 1984, USA	50 patients with ingested intra-corporeal cocaine packets (number of packets passed per patient 54-182)	Retrospective cohort	Complete passage of packets per rectum using conservative management	44 patients	Treatment environment unknown Time from admission to onset of symptoms in the three patients who developed complications unknown
			Elective surgery	6 patients (their own choice)
			Complications of conservative management	3 patients required emergency surgery for obstruction
Aldrighetti L et al, 1996, Italy	61 asymptomatic suspected smugglers with ingested intra-corporeal packets of cocaine (number of packets ingested per patient 52-117)	Retrospective cohort	Complete passage of packets per rectum using conservative management.	61 patients	Treatment environment unknown Time from admission to onset of symptoms in the obstructed patient unknown
			Complications of conservative management	2 patients required emergency surgery: 1 obstruction, 1 cocaine toxicity (on day 3 of admission)
Bulstrode N et al, 2002, UK	180 suspected smugglers with ingested intra-corporeal packets of contraband (number of packets per patient: 2-217)	Retrospective cohort	Complete passage of packets per rectum using conservative management	144 asymptomatic body packers	Several key details unknown, for example exact management of the 144 packers who were not admitted and discharge criteria

Comment(s)

It has generally become accepted that cocaine body packers who show signs of cocaine toxicity or gastrointestinal obstruction need emergency surgery. Additionally, when packets show signs of in vivo degradation (passing pieces of sloughed packet wrappings or actual packets with deteriorated packaging) emergency surgery may also be warranted. The general management plan in asymptomatic cocaine body packers would seem to be conservative management consisting of mild laxatives and light solid or clear liquid diet with close monitoring and intravenous access maintenance throughout. Treatment usually ceases with the passage of at least two packet free stools, with or without supporting radiographic data (abdominal radiography/KUB), and only McCarron and Wood suggest using suppositories to obtain non-obstructing, intra-rectal packets. That said, details such as management environment (intensive care/high dependency unit, emergency department, or general ward?) still remain unclear, and because none of the series mentioned above are prospective, randomized control trials, the validity of their results can also be called into question.

Clinical Bottom Line

The best evidence available suggests that asymptomatic cocaine body packers should be managed conservatively till they have completely passed their packets. Close clinical observation in the meantime allows for the early detection of patients developing complications that may require emergency surgery.

References

1. McCarron MM, Wood JD. The cocaine body packer syndrome. Diagnosis and treatment. JAMA 1983;250:(11):1417-20.
2. Caruana DS, Weinbach B, Goerg D, et al. Cocaine-packet ingestion. Annals of Internal Medicine 1984;100:73-4.
3. Aldrighetti L, Paganelli M, Giacomelli M, et al. Conservative management of cocaine-packet ingestion: experience in Milan, the main Italian smuggling centre of South American cocaine. Panminerva Med 1996;38:111-6.
4. Bulstrode N, Banks F, Shrotria S. The outcome of drug smuggling by 'body packers' - the British experience. Annals of the Royal College of Surgeons of England 2002;84:35-8.