Elsevier

Clinical Imaging

Volume 79, November 2021, Pages 244-250
Clinical Imaging

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

https://doi.org/10.1016/j.clinimag.2021.05.012Get rights and content

Highlights

  • Low dose CT is commonly used to identify in corpore drug transportation.

  • While drug packets are mainly hyperdense on CT, they can sometimes have a lower density.

  • Sagittal and coronal reconstructions, as well as three-dimensional rendered views are often helpful to detect hyperattenuating drug packets

  • If too many packets are located in the stomach, the patient should be transferred to intensive care unit for surveillance because of a high risk of rupture.

Abstract

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 corporeillicit drug transportation, and should know situations that may alter drug smugglers management.

Introduction

Illicit drugs are predominantly transported around the world by sea, road/train or air transport in different ways of packaging. Concealment within a person's body is a frequent mode of transportation for small quantities of drugs.1 The most frequent method of concealment is oral ingestion of drug containing packets (i.e., the so-called “body packing”). When “in corpore” drug transportation is suspected, imaging is the best option to confirm the assumption. Despite a sensitivity ranging from 40% to 90%,[2], [3], [4], [5] plain abdominal X-ray has been the most frequently used imaging modality for several years, but has been abandoned due to low negative predictive value.6 Computed tomography (CT) is however known as the most effective method to identify abdominopelvic drug packets2,4,7,8 but at the penalty of greater radiation compared to conventional radiography. The introduction of low dose CT protocol recently changed the imaging approach of “in corpore” drug transportation.7,[9], [10], [11], [12] Indeed, the effective radiation dose for a low dose abdominal CT is now around 1.06–2.05 mSv,7,9,10,13,14 while the mean effective radiation dose for a conventional abdominal radiograph is around 0.7 mSv, with reported ranges of 0.4–1.1 mSv.15,16 By comparison, the mean effective radiation dose for standard CT protocol is estimated around 9 mSv.11 In general, the visibility of drug packets on low dose CT images is not reduced by comparison with standard CT.17,18 However, the visibility may be altered for small packets in stuffer patients, but this would require further investigations. The radiologist has a fundamental role in the medicolegal process of identification of “in corpore” drug transportation.19 However, some situations may be challenging for less experienced radiologists.

The purpose of this review was to illustrate the imaging characteristics of “in corpore” drug transportation on CT examination, with a special emphasis on low-dose CT.

Section snippets

Definitions

There are generally three types of “in corpore” drug transportation. The most common one is “body packing”, which consists of the oral ingestion of several drug packets in order to pass the frontier of a country. Body packers are also referred to as “swallowers”, “couriers”, “internal carriers” or “(drug) mules”.20 Those drugs packets are often coated with paraffin or fiberglass (“manufactured”) in order to lower the risk of perforation (Fig. 1).21 The second type is “body pushing”, which

Indication and protocol

Abdominal low dose CT can be requested by authorities whenever “in corpore” drug transportation is suspected. It is also often requested in a pre-discharge context, to ensure the absence of residual drug packets.23 From a medical point of view, abdominal CT also helps diagnose complications that could lead to specific care. In pregnant women and children however, a radiating imaging technique such as ultrasonography24,25 or magnetic resonance imaging26 is recommended, but at the penalty of

Drug types

Illicit drugs have various presentations on CT examination. Some in vitro studies tried to evaluate attenuation values of several drugs.32,33 In this regard, pure heroin has a mean attenuation value of −520 Hounsfield units (HU) (between fat and air attenuation), pure cocaine of −219 HU (more hypoattenuating than fat), pure hashish of +700 HU (similar to the bone), and pure methamphetamine of −100 to 150 HU.31 However, those attenuation values greatly vary according to concentrations and degree

Key points for the radiological report

A simple and structured report is needed for drug smuggler's CT reports. If possible, the radiologist must describe the exact number of drug packets. The risk of counting error is greater with the number of packets, it is recommended to indicate a range of numbers in the report instead of the exact number when there are more than 20 packets. Sagittal and coronal reconstructions, as well as three-dimensional rendered views are often helpful to detect hyperattenuating drug packets (Fig. 2).1,31

Conclusion

Low dose abdominal CT is now essential for the diagnosis of “in corpore” illicit drug transportation. Radiologists have a fundamental role in the medicolegal process of drug smuggling diagnosis. A simple and structured report is advised for drug smuggler's CT reports. Major information such as the number of packets, the exact location and the aspects of drug packets must be written. The radiologist must be aware of the imaging characteristics of “in corpore” illicit drug transportation, and

Funding

None.

Availability of data and material

Not applicable.

Code availability

Not applicable.

Declaration of competing interest

None.

References (52)

  • A.A. Abedzadeh et al.

    New packaging methods of body packers: role of advanced imaging in their detection. A case study

    Radiol Case Rep

    (2019)
  • R. June et al.

    Medical outcome of cocaine bodystuffers

    J Emerg Med

    (2000)
  • S.A. Koehler et al.

    The risk of body packing: a case of a fatal cocaine overdose

    Forensic Sci Int

    (2005)
  • G. Sica et al.

    Imaging of drug smuggling by body packing

    Semin Ultrasound CT MR

    (2015)
  • J.G. Eng et al.

    False-negative abdominal CT scan in a cocaine body stuffer

    Am J Emerg Med

    (1999)
  • S. Cappelletti et al.

    Systematic review of the toxicological and radiological features of body packing

    Int J Legal Med

    (2016)
  • J. Hierholzer et al.

    Drug smuggling by ingested cocaine-filled packages: conventional X-ray and ultrasound

    Abdom Imaging

    (1995)
  • S.J. Traub et al.

    Body packing—the internal concealment of illicit drugs

    N Engl J Med

    (2003)
  • R. Beerman et al.

    Radiographic evaluation of the cocaine smuggler

    Gastrointest Radiol

    (1986)
  • Costello J, Townend W. Best evidence topic report. Abdominal radiography in “body packers.” Emerg Med J 2004;21:498....
  • P.-A. Poletti et al.

    Screening of illegal intracorporeal containers (“body packing”): is abdominal radiography sufficiently accurate? A comparative study with low-dose CT

    Radiology

    (2012)
  • P.J. Karhunen et al.

    Pitfalls in the diagnosis of drug smuggler’s abdomen

    J Forensic Sci

    (1991)
  • J. Aissa et al.

    Low-tube voltage 100 kVp MDCT in screening of cocaine body packing: image quality and radiation dose compared to 120 kVp MDCT

    Abdom Imaging

    (2015)
  • H. Bahrami-Motlagh et al.

    Comparison of low dose and standard dose abdominal CT scan in body stuffers

    Clin Toxicol

    (2018)
  • J. Aissa et al.

    Optimizing radiation exposure in screening of body packing: image quality and diagnostic acceptability of an 80 kVp protocol with automated tube current modulation

    Forensic Sci Med Pathol

    (2017)
  • G. Pache et al.

    Low-dose computed tomography for the detection of cocaine body packs: clinical evaluation and legal issues

    ROFO

    (2012)
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