Pediatric body packing: drug smuggling reaches a new low

Endoscopic Management of Ingested Narcotic Substances: A Case Report and Literature Review

Management of swallowed narcotics remains in contention despite the increased frequency of occurrence. International societies recommend conservative therapy with escalation to surgical interventions in cases where drug packets do not progress. However, multiple studies demonstrate a treatment benefit of endoscopic intervention. We report the case of a 27-year-old male who presented after ingesting heroin bundles and failed the 48-hour of conservative therapy. Repeat computed tomography scanning demonstrated no movement of the package. Endoscopic retrieval was successful, and the patient was discharged the same day. Endoscopic intervention in the removal of bagged narcotics should be considered in patients presenting after purposely ingesting narcotics as means of planned concealment. 

Foreign object ingestion and esophageal food impaction: An update and review on endoscopic management

Foreign body ingestion encompasses both foreign object ingestion (FOI) and esophageal food impaction (EFI) and represents a common and clinically significant scenario among patients of all ages. The immediate risk to the patient ranges from negligible to life-threatening, depending on the ingested substance, its location, patient fitness, and time to appropriate therapy. This article reviews the FOI and EFI literature and highlights important considerations and implications for pediatric and adult patients as well as their providers. Where published literature is insufficient to provide evidence-based guidance, expert opinion is included to supplement the content of this comprehensive review.

Noise insertion in CT for cocaine body packing: where is the limit of extensive dose reduction?

Background

To evaluate the detection rate and image quality in CT-body-packer-screening at different radiation-dose levels and to determine a dose threshold that enables a reliable detection of incorporated body packs and incidental findings with a maximum of dose saving.

Materials and methods

We retrospectively included 27 individuals who underwent an abdominal CT with automated exposure control due to suspected body packing. CT images were reconstructed at different radiation-dose levels of 50%, 10, 5% and 1% using iterative reconstructions. All 135 CT reconstructions were evaluated by three independent readers. Reviewers determined the presence of foreign bodies and evaluated the image quality using a 5-point ranking scale. In addition, visualization of incidental findings was assessed.

Results

A threshold of 5% (effective dose 0.11 ± 0.07 mSv) was necessary to correctly identify all 27 patients with suspected body packing. Extensive noise insertion to a dose level of 1% (0.02 ± 0.01 mSV) led to false-positive solid cocaine findings in three patients. Image quality was comparable between 100 and 50%. The threshold for correct identification of incidental findings was 10% of the initial dose (effective dose 0.21 ± 0.13 mSv).

Conclusions

Our results indicate that dose of abdominal CT for the detection of intracorporeal cocaine body packets can be markedly reduced to up to 5% of the initial dose while still providing sufficient image quality to detect ingested body packets. However, a minimum effective dose of 0.21 mSv (10% of initial dose) seems to be required to properly identify incidental findings.

Caustic Ingestions and Foreign Bodies Ingestions in Pediatric Patients

Children inevitably swallow foreign material accidentally or intentionally. Each type of ingestion carries their own set of risks and complications, short and long term, some requiring immediate attention while others close monitoring. Alkalotic household cleaning products and lithium button batteries are increasingly common and damage the esophagus quickly. While many toys with rare-earth metals are banned, they are already present in many households and can cause necrosis of bowel that is between the magnets. This article reviews the incidence and assessment along with current literature to provide guidelines for management of pediatric patients with suspected caustic or foreign body ingestion.

Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines

This guideline refers to infants, children, and adolescents ages 0 to 18 years. The areas covered include indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; corrosive ingestion and stricture/stenosis endoscopic management; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography; and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease has been dealt with in other guidelines and are therefore not mentioned in this guideline. Training and ongoing skill maintenance are to be dealt with in an imminent sister publication to this.

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.

Review of foreign body ingestion and esophageal food impaction management in adolescents

Foreign body ingestion is a common clinical scenario among patients of all ages. The immediate risk to the patient ranges from negligible to life threatening. Initial and follow-up management strategies depend on multiple patient and ingested object-related factors. Available literature on this topic tends to focus on the small child or adult, leaving the clinician caring for adolescents to extrapolate this information to guide decision making for individual patients. This article reviews foreign body ingestion literature with important implications to the adolescent patient and raises awareness of some highly dangerous objects such as large button batteries, high-powered magnets, long sharps, narcotic packages, and super absorbent objects. An additional focus includes the management of esophageal food impaction. We highlight the unique aspects to the care of the adolescent with intentional ingestion and co-morbid psychiatric illness. The article concludes by discussing the challenges to prevention of ingestion in the at-risk patient.

Comparison of diagnostic value of multidetector computed tomography and X-ray in the detection of body packing

OBJECTIVE

Radiologists and other clinicians are facing an increasing number of illegal drug-related medical conditions. We aimed to draw attention to this growing global problem and to highlight some of the important points related to diagnosis and follow-up of body packing. We compare the diagnostic performance of unenhanced multidetector CT (MDCT) and abdomen X-ray for the detection of drug-filled packets.

MATERIALS AND METHODS

Sixty-seven suspects, who underwent both CT and X-ray examinations, have been included in the study. All MDCT and X-ray images were independently and retrospectively reviewed by two observers with different degrees of experience in abdomen imaging. Fifty-two of them were identified as body packers finally. Interobserver agreement, sensitivity, specificity, positive and negative predictive value were calculated.

RESULTS

Two types of packets with different characteristics were identified in all body packers. Type 1 packets (solid-state drug) were found in 41 patients and type 2 packets (liquid cocaine) in 11 patients. All statistical analyses concern the detection of any packets. That is, the whole evaluation has been performed per patient. Sensitivity/specificity values of type 1 and type 2 packets for MDCT were 100-98%/100-100% and 100-100%/100-100%, respectively. Besides, sensitivity/specificity values of type 1 and type 2 packets for X-ray were 93-90%/100-91% and 64-45%/73-71%, respectively. In addition, interobserver agreements for detection of any packets were excellent (κ=0.96) and good (κ=0.75) for interpretation of MDCT and X-ray, respectively.

CONCLUSION

Unenhanced MDCT is a fast, accurate and easily used diagnostic tool with high sensitivity and specificity for the exact diagnosis of body packing.