Characteristic imaging features of body packers: a pictorial essay

Using CT scout view to scan illicit drug carriers may reduce radiation exposure

OBJECTIVE

The aim of this study was to present our experience on the evaluation of suspected illicit drug carriers via computerized tomography scout view (CTSV) with analysis of detectability and features such as content, form and density.

METHODS

A total of 120 individuals suspected of body packing were screened via CT in a university emergency department between January 2014 and December 2017.

RESULTS

88.3% of 120 body packing cases examined in the study were male. The median (1st quartile-3rd quartile) age of the cases was 35.5 (30-41) years. We found that solid packs have a 4.573-fold higher likelihood of detection in CTSV screening than liquid ones (95%CI: 1.879-11.134). Additionally, the number of CT scans needed were significantly associated with capsule localization (stomach) (OR:7.178, 95%CI: 2.420-21.293) and solid form packs (OR: 8.705, 95%CI: 2.318-32.692) are associated with number of CT scans.

CONCLUSION

CTSVs have a successful detection rate, especially in solid form packs. Our results suggest that conclusive CTSV imaging for body packing may be recommended to delay the application of the next CT scan until the passage of the first capsule; thereby preventing unnecessary radiation exposure.

Body packing, body stuffing and body pushing: Characteristics and pitfalls on low-dose CT

Because of availability and low radiation dose level, low dose computed tomography (CT) is now commonly used to identify illicit in corpore drug transportation. This review illustrates the most common CT findings of in corpore drug transportation and describes complications due to in corpore drug transportation, with a special emphasis on low dose CT. Major information such as number of packets, exact location and aspect of packets must be assessed. Radiologist must be aware of the imaging characteristics of "in corpore" illicit drug transportation, and should know situations that may alter drug smugglers management.

Imaging of drug mules

Cocaine, heroin, methamphetamine, and hashish are the primary drugs transported by a body packer, who swallows such packages. A body pusher or stuffer transports drug packages in rectum or vagina. Plain radiography is the primary imaging modality used in the evaluation of concealed drugs and has sensitivity of 85-90%. The imaging features include well-defined opacities in the bowel with crescents of air near ovoid opacities. The imaging signs include double condom sign, halo sign, parallelism sign, and tic tac sign. A low-dose CT is an efficient noninvasive and accurate technique of locating packages internally for all types of concealment.

Management recommendations for body stuffers at emergency units

Managing body packers and stuffers is a challenge to emergency physicians, stuffers in particular, as there is no systematic approach to their treatment. The aim of this study was therefore to review all available literature on body stuffing and propose a guide to manage these patients. We searched Medline/PubMed, Google Scholar, and Scopus for published work on body stuffers using key words "body stuffer", "body stuffing", "poisoning", "toxicity", and "treatment" without a time limit and retrieved 290 articles, of which 61 remained after exclusion of those on "body packers" and repetitive documents. This review article evaluates and summarises the information gathered from them. The main step in body stuffer management is observation to make sure that they have passed all the swallowed packages of drugs of abuse. In some cases, imaging can be quite useful. Diagnostic pitfalls may be avoided with abdominopelvic CT without contrast, which is probably the best diagnostic method to determine the presence and the number of packages in these patients. Treatment should be specific for each group of drugs, whether it is opioids, cocaine, or amphetamine. Surgical interventions are indicated for obstruction of the intestines or package rupture. Legal precautions should be taken because of the legal complexity of body stuffing cases.

Death by "Snow"! A Fatal Forensic Case of Cocaine Leakage in a "Drug Mule" on Postmortem Computed and Magnetic Resonance Tomography Compared With Autopsy

This forensic case presents unique postmortem imaging of a "drug mule" with fatal intoxication due to cocaine leakage on postmortem computed and magnetic resonance (MR) tomography compared with autopsy.Imaging by postmortem computed and MR tomography was performed before autopsy, histology, and toxicology were commissioned. Forensic imaging revealed 91 hyperdense, uniformly shaped body packs with signs of leakage, which was confirmed by autopsy. Postmortem MR imaging displayed the rarely described hypointense appearance of the body packs in T1- and T2-weighted sequences. Toxicology stated the dosage of cocaine intoxication as lethal.This case provides an opportunity to image internal cocaine drug containers on postmortem computed and MR tomography. The cause of death could be determined based on imaging and the radiological morphology of these packs by both imaging methods.

The role of radiology in diagnosis and management of drug mules: an update with new challenges and new diagnostic tools

Emergency physicians and radiologists have been increasingly encountering internal concealment of illegal drugs. The packages commonly contain powdered solid drugs such as cocaine, heroin, methamphetamine and hashish, but they may also contain cocaine in the liquid form. The second type of package has recently been more commonly encountered, and poses a greater diagnostic challenge. As clinical evaluation and laboratory tests frequently fail to make the correct diagnosis, imaging examination is typically required. Imaging methods assume a vital role in the diagnosis, follow-up and management. Abdominal X-ray, ultrasonography, CT and MRI are used for the imaging purposes. Among the aforementioned methods, low-dose CT is state-of-the-art in these cases. It is of paramount importance that radiologists have a full knowledge of the imaging characteristics of these packages and accurately guide physicians and security officials.

Imaging of drug smuggling by body packing

Body packing, pushing, and stuffing are hazardous practices with complex medicolegal and social implications. A radiologist plays both a social and a medicolegal role in their assessment, and it should not be limited only to the identification of the packages but must also provide accurate information about their number and their exact location so as to prevent any package remains in the body packer. Radiologists must also be able to recognize the complications associated with these risky practices. Imaging assessment of body packing is performed essentially through plain abdominal X-ray and computed tomography scans. Ultrasound and magnetic resonance imaging, although with some advantages, actually have a limited use.

Walking on thin ice! Identifying methamphetamine "drug mules" on digital plain radiography

OBJECTIVE

The purpose of this study was to retrospectively evaluate the sensitivity, specificity and accuracy of identifying methamphetamine (MA) internal payloads in "drug mules" by plain abdominal digital radiography (DR).

METHODS

The study consisted of 35 individuals suspected of internal MA drug containers. A total of 59 supine digital radiographs were collected. An overall calculation regarding the diagnostic accuracy for all "drug mules" and a specific evaluation concerning the radiological appearance of drug packs as well as the rate of clearance and complications in correlation with the reader's experience were performed. The gold standard was the presence of secured drug packs in the faeces.

RESULTS

There were 16 true-positive "drug mules" identified. DR of all drug carriers for Group 1 (forensic imaging experienced readers, n = 2) exhibited a sensitivity of 100%, a mean specificity of 76.3%, positive predictive value (PPV) of 78.5%, negative predictive value (NPV) of 100% and a mean accuracy 87.2%. Group 2 (inexperienced readers, n = 3) showed a lower sensitivity (93.7%), a mean specificity of 86%, a PPV of 86.5%, an NPV of 94.1% and a mean accuracy of 89.5%. The interrater agreement within Group 1 was 0.72 and within Group 2 averaged to 0.79, indicating a fair to very good agreement.

CONCLUSION

DR is a valuable screening tool in cases of MA body packers with huge internal payloads being associated with a high diagnostic insecurity. Diagnostic insecurity on plain films may be overcome by low-dose CT as a cross-sectional imaging modality and addressed by improved radiological education in reporting drug carriers on imaging.

ADVANCES IN KNOWLEDGE

Diagnostic signs (double-condom and halo signs) on digital plain radiography are specific in MA "drug mules", although DR is associated with high diagnostic insecurity and underreports the total internal payload.

Radiological and practical aspects of body packing

Body packing represents the concealment of illegal substances in a person's body with the aim of smuggling. "Body packers" either swallow drug-filled packets or introduce drug-filled packets into their bodies rectally or vaginally with the purpose of concealing them. The three main smuggled drugs are cocaine, heroin and cannabis products. Body packing represents a serious risk of acute narcotic toxicity from drug exposure, intestinal obstruction owing to pellet impaction and bowel perforation with consequent abdominal sepsis. A suspected body packer is generally admitted to hospital to perform imaging investigations and confirm the presence of drugs in his/her body. Radiological imaging methods are essential to diagnose body packing and to detect potential complications. Increasing sophistication of traffickers and improvements in packaging add to the detection difficulty. Radiologists should be aware of the appearance of drug packets in a range of imaging modalities. This article informs physicians about the challenging aspects of body packing, its background and medicolegal issues, what imaging methods can be used and what criteria are necessary to perform a correct diagnosis.

Detection of body packing by magnetic resonance imaging: a new diagnostic tool?

PURPOSE

In this study, we aimed to describe non-contrast abdominal MRI findings in body packers and emphasize the role of this imaging technique in diagnosis of body packing.

MATERIALS AND METHODS

Non-contrast abdominopelvic MRI was performed at the radiology department in 16 suspected body packers that were brought to our hospital, and 13 of them were diagnosed with body packing. We evaluated the presence, location, and shapes of packets as well as signal characteristics on T1- and T2-weighted images.

RESULTS

We came across two types of packets: those containing solid substances (10 cases) and those filled with liquid cocaine (3 cases). Both types were accurately diagnosed with the help of MRI. Only 1 suspected body packer received a false positive diagnosis.

CONCLUSION

Abdominopelvic MRI is a reliable and valuable method of diagnosing body packing.