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 do something more aggressive to remove the packages from the patient’s intestines.

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]?

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 57 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 five 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 table 5.

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 radiograph/ 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, randomised 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 can be managed conservatively until 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.