Diagnostic Imaging Pathways - Drug Trafficking (Suspected)
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Population Covered By The Guidance
This pathway provides guidance on the imaging of patients suspected of concealing drugs within their alimentary tract (“body packers”).
Date reviewed: September 2018
Date of next review: September 2021
Published: March 2019
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Teaching Points
Teaching Points
- 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
axr
Plain Abdominal Radiograph
- Plain radiograph of the abdomen (AXR) is the most commonly used radiological examination to detect drug-filled packets 1-6
- Advantages include involving a lower radiation dose, being relatively inexpensive, fast and widely available 2
- The sensitivity of AXR to detect solid-state drug packets has been shown to be as high as 85-93.5% 1, 7, 8 but lower sensitivities are reported for liquid cocaine (45-64%). 7 Schulz et al reported a positive predictive value of 20% for AXR and negative predictive value of 81%. 9 False negatives may arise due to difficulties delineating the packet margins from residual bowel contents 8
- AXR is less sensitive for lesser numbers of packets. 10 The reported sensitivity for detecting residual packets was only 28%, so a AXR is not recommended to clear patients for discharge 11
- 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 5,12
- 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. 1,2,10 Occasionally, they are arranged in parallel within the bowel lumen (‘parallelism’) 1,2
ct
Abdominal Computed Tomography
- Computed tomography (CT) is the most sensitive method for detecting ingested drug packages. 8,13 It should be used when an AXR is negative, but drug packing is still strongly suspected 2,3,5,8
- 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% 8,13
- Low-dose protocols have been shown to be accurate for detecting packets 13 and are preferred over conventional dose CT 2
- If not already performed prior, low-dose unenhanced CT is the preferred investigation prior to discharge to rule out retained packets 11
- Manipulation of the windowing outside of the standard abdominal window can better identify isodense foreign bodies and air in packaging 2,8
- CT is also useful for the identification of any associated complications like intestinal obstruction and perforation 1
- MRI and ultrasound can be considered for children and pregnant women to avoid ionising radiation 2
References
References
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
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