Detection of ingested cocaine-filled packets—Diagnostic value of unenhanced CT
Introduction
Emergency departments face an increasing number of drug-related health problems, with difficult medicolegal and social consequences. Over the last two decades, drug smuggling has not only increased worldwide, but the gastrointestinal tract has been also used more frequently as a vehicle for smuggling narcotics [1], [2], [3], [4], [5]. Body packing and body stuffing are the terms employed for intracorporeal concealment of illicit drugs, mainly cocaine and heroine [6]. Body packers fill their gastrointestinal tract with large bags (2–8 cm) [7], [8] containing narcotics prior to crossing international borders, in order to retrieve them after arrival at their destination. Their drug bags are generally carefully packed and wrapped in containers designed to gastrointestinal tract transit.
In contrast, body stuffers, also called mini-packers, are usually street dealers, often drug abusers themselves [9], who either store or unexpectedly and hastily hide one or several small packets of drugs in their body cavities, when prompted by fear of police's arrest. They either swallow them or introduce them into the vagina or rectal ampulla in order to escape detection by law enforcement authorities. The most commonly involved drug is cocaine [5]. Each of these cocaine-filled packets (CFP) measures 8–10 mm, and consists of about 1 g of cocaine powder of variable purity (5–20%), often insecurely wrapped in several layers of packing material of varying type, including plastic wraps, plastic bags, cellophane paper, aluminum foil, glassine crack and condoms [10]. These CFP are therefore not specifically prepared for gut transit and especially prone to rupture or leakage within the intestine, depending on the wrapping method and the material used [11]. Since the number of ingested CFP ranges from 1 to 25, up to 5 g of pure cocaine may thus simultaneously be present within the digestive tract. The absolute lethal dose in human beings after oral intake is 1.2 g with an LD50 of approximately 500 mg [12]. Therefore, leakage of CFP can trigger lethal complications [13]. Clinicians need to detect the presence of CFP in the gastrointestinal tract in order to monitor patients for signs of cocaine toxicity.
While the diagnostic management of body packers has often been described in the literature [3], [4], [14], [15], [16], the optimal imaging modality of body stuffers is poorly delineated, and remains controversial. Plain abdominal films are of limited value, mainly because of the small size and amount of drugs ingested by body stuffers, unlike the large drug bags incorporated by body packers. Several case reports [2], [14], [17], [18] describe the use of computed tomography (CT) to detect CFP. However the precise diagnostic performance of CT has not been assessed.
We therefore evaluated the diagnostic value of unenhanced multidetector CT (MDCT) for the detection of cocaine-filled packets (CFP) using a phantom model.
Section snippets
Materials and methods
Using an eight-row detector CT unit (Lightspeed Ultra, GE Healthcare, Milwaukee, Wisconsin, USA), we performed a phantom study simulating two types of physiological bowel content: a solid medium made from boiled rice and noodles mixed with a small amount of ultrasound gel (Polaris, Allerbio, Varennes-en-Argonne, France) and a liquid medium only composed of the ultrasound gel. Creating our solid medium, we paid very much attention to its imaging appearance and CT density, which varied from −135
Results
The individual reading performance for each of the four observers for detection of any, and the true or false CPF is shown in Table 1. Overall sensitivity, specificity, positive (PPV) and negative (NPV) predictive value for true CFP detection were 86.5%, 100%, 100% and 77.6%, respectively. Overall accuracy for counting the exact number of true and false CPF was 63.9% and 81.9%, respectively, the values for each observer are shown in Table 2.
Interobserver agreement kappa between the four
Discussion
Plain abdominal X-ray is the most widely used radiological tool to detect drug-filled packets of 2–8 cm within the gastrointestinal tract of body packers [3], [7], [8], [16]. However, due to limited contrast resolution, conventional radiographs (CR) of body packers reveal the presence of drug containers in 40–90% of cases only [1], [3], [4], [14], [20], [21], [22]. Up to 60% of these large ingested drug bags may therefore remain undetected. The far smaller CFP ingested by body stuffers are
Conclusion
Unenhanced MDCT without bowel preparation is a fast, reliable and easily reproducible imaging modality for the immediate detection of ingested CFP. Major diagnostic criterion is an outer halo of air trapped within the wrapped cellophane surrounding the spherical and central cocaine, of high-attenuation in our study. Lack of this air crescent may create false negative results, while scybala surrounded by an air–solid inferface and present in the stool of body stuffers can be responsible for
References (24)
- et al.
The cocaine “body stuffer” syndrome: a fatal case
Forensic Sci Int
(2002) - et al.
The bodystuffer syndrome: a clandestine form of drug overdose
Am J Emerg Med
(1986) - et al.
Medical outcome of cocaine bodystuffers
J Emerg Med
(2000) - et al.
Cocaine liberation from body packets in an in vitro model
Ann Emerg Med
(1992) - et al.
Two crack cocaine body stuffers
Ann Emerg Med
(1992) - et al.
False-negative abdominal CT scan in a cocaine body stuffer
Am J Emerg Med
(1999) - et al.
Clinical course of crack cocaine body stuffers
Ann Emerg Med
(1997) - et al.
The cocaine body-packer syndrome: evaluation of a method of contrast study of the bowel
J Forensic Sci
(1990) - et al.
CT of crack cocaine ingestion
J Comput Assist Tomogr
(1992) - et al.
Drug smuggling by ingested cocaine-filled packages: conventional x-ray and ultrasound
Abdom Imaging
(1995)