Population Covered By The Guidance
This pathway provides guidance on the imaging of patients suspected of concealing drugs within their alimentary tract (“body packers”).
Lead Researcher: Sian Chin
Experts & Contributors: Ravinder Dhillon, Richard Mendelson, Yusuf Nagree, Mohan Raghavan
Editorial Panel: Core membership
Link to Editorial Panel
Date reviewed: September 2018
Date Published: March 2019
- Body packers conceal illicit drugs by ingesting drug-containing packets to avoid detection at border crossings or airport customs
- Conversely, body pushing refers to inserting packets in the rectum or vaginal cavity. These can usually be detected by physical examination
- The role of imaging is to confirm the presence of packets, the number of packets, and to evaluate patients who may have complications of body packing such as obstruction or perforation
- Plain abdominal radiography (AXR) is commonly the first investigation for screening for ingested drug packages but is less sensitive for body stuffers carrying fewer packages, smaller packages or liquid cocaine
- If AXR is normal, but drug packing is still suspected, a low-dose CT abdomen should be performed Low-dose CT abdomen is the investigation of choice to rule out ingested packets. CT should be performed prior to discharge if there is concern about retained packages , or if a CT has not been performed prior
- MRI and ultrasound can be considered for children and pregnant women to avoid ionising radiation, but there is no published evidence for their efficacy
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Niewiarowski S, Gogbashian A, Afaq A, Kantor R, Win Z.Abdominal x-ray signs of intra-intestinal drug smuggling. Journal of forensic and legal medicine. 2010;17(4):198-202. (Level III evidence). View the reference
- Bulakci M, Cengel F.The role of radiology in diagnosis and management of drug mules: an update with new challenges and new diagnostic tools. The British Journal of Radiology. 2016;89(1060):20150888. (Review article). View the reference
- Traub SJ, Hoffman RS, Nelson LS.Body packing — the internal concealment of illicit drugs. N Engl J Med. 2003;349(26):2519-26. (Review article). View the reference
- Horrocks AW.Abdominal radiography in suspected 'body packers'. Clin Radiol. 1992;45(5):322-5. (Level II evidence). View the reference
- Hergan K, Kofler K, Oser W. Drug smuggling by body packing: what radiologists should know about it. Eur Radiol. 2004;14(4):736-42. (Review article). View the reference
- Bulstrode N, Banks F, Shrotria S.The outcome of drug smuggling by 'body packers'--the British experience. Ann R Coll Surg Engl. 2002;84(1):35-8. (Level III evidence). View the reference
- Bulakci M, Kalelioglu T, Bulakci BB, Kiris A.Comparison of diagnostic value of multidetector computed tomography and X-ray in the detection of body packing. Eur J Radiol. 2013;82(8):1248-54. (Level II-III evidence). View the reference
- Yang RM, Li L, Feng J, Lai SS, Lin BQ, Yu T, et al.Heroin body packing: clearly discerning drug packets using CT. South Med J. 2009;102(5):470-5. (Level III evidence). View the reference
- Schulz B, Grossbach A, Gruber-Rouh T, Zangos S, Vogl TJ, Eichler K.Body packers on your examination table: How helpful are plain x-ray images? A definitive low-dose CT protocol as a diagnosis tool for body packers. Clin Radiol. 2014;69(12):e525-30. (Level II-III evidence). View the reference
- Poletti PA, Canel L, Becker CD, Wolff H, Elger B, Lock E, et al. Screening of illegal intracorporeal containers ("body packing"): is abdominal radiography sufficiently accurate? A comparative study with low-dose CT. Radiology. 2012;265(3):772-9. (Level II-III evidence). View the reference
- Rousset P, Chaillot PF, Audureau E, Rey-Salmon C, Becour B, Fitton I, et al. Detection of residual packets in cocaine body packers: low accuracy of abdominal radiography-a prospective study. Eur Radiol. 2013;23(8):2146-55. (Level II-III evidence). View the reference
- Berger FH, Nieboer KH, Goh GS, Pinto A, Scaglione M.Body packing: a review of general background, clinical and imaging aspects. La Radiologia medica. 2015;120(1):118-32. (Review article). View the reference
- Laberke PJ, Blum S, Waelti S, Fornaro J, Hausmann R, Alkadhi H, et al.Systematic evaluation of radiation dose reduction in CT studies of body packers: accuracy down to submillisievert levels. AJR Am J Roentgenol. 2016;206(4):740-6. (Level II-III evidence). View the reference
Pathway User Guide
Yellow Boxes Denotes extra information. Some contain single or multiple white sub-boxes, click a white box to reveal detailed information in a pop-up.
White Boxes: Denotes standard pathway steps. (If inside a yellow box, they open a specific pop-up).
Zoom & Pan Controls: Use + / − or the slider to zoom. Reset returns to default. Tick Panning to drag the diagram when zoomed.
Blue “View Full Screen” Button: Opens the whole diagram in a large, full-screen pop-up window. Use Close to exit.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
|---|---|---|
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Disclaimer
Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
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Plain Abdominal Radiograph
Plain Abdominal Radiograph
Standard screening tool for ingested drug packages but less sensitive for fewer, smaller packages
- Plain radiograph of the abdomen (AXR) is the most commonly used radiological examination to detect drug-filled packets
- Advantages include involving a lower radiation dose, being relatively inexpensive, fast and widely available
- The sensitivity of AXR to detect solid-state drug packets has been shown to be as high as 85-93.5% , , but lower sensitivities are reported for liquid cocaine (45-64%). Schulz et al reported a positive predictive value of 20% for AXR and negative predictive value of 81%. False negatives may arise due to difficulties delineating the packet margins from residual bowel contents
- AXR is less sensitive for lesser numbers of packets. The reported sensitivity for detecting residual packets was only 28%, so a AXR is not recommended to clear patients for discharge
- The density of drug packages varies depending on the composition, state (liquid or solid), the degree of purity and the materials & techniques used in packaging including packing density
- The most common radiographic findings in body packers are spherical or cylindrically shaped densities throughout the abdomen (‘tic-tac’ sign), sometimes surrounded by thin rims of air (‘double condom’ sign) or clearly outlined by dense wrapping material. Occasionally, they are arranged in parallel within the bowel lumen (‘parallelism’)
Abdominal Computed Tomography
Abdominal Computed Tomography
Most sensitive investigation for detecting ingested packets. Low dose protocols have been shown to be as accurate as conventional dose CT
- Computed tomography (CT) is the most sensitive method for detecting ingested drug packages. It should be used when an AXR is negative, but drug packing is still strongly suspected
- Unenhanced CT has been shown to be a fast, accurate and easily reproducible imaging modality for the detection of ingested drug filled packets. Sensitivity is generally excellent, ranging from 95.6-100%
- Low-dose protocols have been shown to be accurate for detecting packets and are preferred over conventional dose CT
- If not already performed prior, low-dose unenhanced CT is the preferred investigation prior to discharge to rule out retained packets
- Manipulation of the windowing outside of the standard abdominal window can better identify isodense foreign bodies and air in packaging
- CT is also useful for the identification of any associated complications like intestinal obstruction and perforation
- MRI and ultrasound can be considered for children and pregnant women to avoid ionising radiation
Contrast-Enhanced CT Abdominal
Contrast-Enhanced Abdominal Computed Tomography
CT with IV contrast can demonstrate a wide variety of pathologies that may cause haemodynamic compromise, including complications of drug packing. The protocol should be guided by the clinical assessment and the most likely differential diagnoses