Diagnostic Imaging Pathways - Drug Trafficking (Suspected)
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This pathway provides guidance on the imaging of patients suspected of concealing drugs within their alimentary tract ('drug packers').
Date reviewed: August 2013
Date of next review: August 2015
Published: August 2013
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
|SYMBOL||RRL||EFFECTIVE DOSE RANGE|
|Minimal||< 1 millisieverts|
- Plain abdominal radiography (AXR) is the first line investigation for screening for ingested drug packages
- If AXR is normal, but drug packing is still suspected, a CT abdomen should be performed
Abdominal Computed Tomography (CT)
- Computated tomography 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%. , Manipulation of the windowing outside of the standard abdominal window can better identify isodense foreign bodies
- CT is also useful for the identification of any associated complications like intestinal obstruction and perforation
- Due to higher cost and ionising radiation burden compared with AXR, it is not appropriate as a screening tool ,
- Body packing can be defined as the intra-abdominal concealment of drugs. Hand or machine made packets containing drugs are swallowed or inserted rectally or vaginally. These drug packets can be made from a variety of materials including condoms, latex, cellophane or other synthetic materials. They are made to form balls or oval shaped objects 2-4cm in size (although inserted packages may be much larger)
- Three main drugs are commonly smuggled with body packing: cannabis products, heroin and cocaine
- The history provided by potential drug traffickers is often unreliable, so radiographic imaging is important to identify body packers and monitor packet evacuation
Plain Abdominal Radiograph
- Plain radiograph of the abdomen (AXR) in an upright and supine position is the most commonly used radiological examination to detect drug-filled packets, and is considered to be the gold standard screening tool
- The sensitivity of AXR to detect drug packets has been shown to be around 85-93.5% in the literature. , False negatives may arise due to difficulties delineating the packet margins from residual bowel contents
- Of the three main drugs transported by body-packers, cocaine is mostly isodense to faeces; heroin is hypodense and cannabis products are hyperdense. However, the density of these drugs may vary depending on their composition, the degree of purity and the materials & techniques used in packaging ,,
- 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’)
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Hergan K, Kofler K, Oser W.Drug smuggling by body packing: What radiologists should know about it. Eur Radiol. 2004;14:736-42. (Review article)
- Traub SJ, Hoffman RS, Nelson LS. Body Packing - The Internal Concealment of Illicit Drugs. N Engl J Med. 2003;349:2519-26. (Review article)
- Horrocks AW.Abdominal radiography in suspected 'body packers'. Clinical Radiol. 1992;45(5):322-5. (Level II evidence) 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;84:35-8. (Level III evidence)
- Niewiarowski S, Gogbashian A, Afaq A, Kantor R, Win Z. Abdominal X-ray signs of intra-intestinal drug smuggling. J Forensic Leg Med. 2010;17:198-202. (Level III evidence)
- Yang R-M, Li L, Feng J, Lai S-S, Bing-Quan Lin M, Yu T, et al. Heroin Body Packing: Clearly Discerning Drug Packets Using CT. South Med J. 2009;102(5):470-5. (Level III evidence)
- Beerman R, Nunez D, Wetli C. Radiographic evaluation of the cocaine smuggler. Gastrointest Radiol. 1986;11:351-4. (Level III evidence)
- Hierholzer J, Cordes M, Tantow H, Keske U, Maurer J, Felix R. Drug smuggling by ingested cocaine-filled packages: conventional X-ray and ultrasound. Abdom Imaging. 1995;20:333-8. (Level II evidence) View the reference
- Algra PR, Brogdon BG, Marugg RC. Role of Radiology in a National Initiative to Interdict Drug Smuggling: The Dutch Experience. AJR Am J Roentgenol. 2007;189:331-6. (Level III evidence)
- Karhunen P, Suoranta H, Penttila A, Pitkaranta P. Pitfalls in the diagnosis of drug smuggler's abdomen. J Forensic Sci. 1991;36(2):397-402. (Level III evidence)
- Prabhu R, Ne'eman A, Bier K, Patel N. Radiology of body packers: The detection of internally concealed illegal materials. Applied Radiology. 2008:26-8. (Review article)
- Schmidt S, Hugli O, Rizzo E, Lepori D, Gudinchet F, Yersin B, et al. Detection of ingested cocaine-filled packets - Diagnostic value of unenhanced CT. Eur J Radiol. 2008;67(1):133-8. (Level II evidence) View the reference
- Sohail S. CT scan of body packers: findings and costs. J Pak Med Assoc. 2007;57:400-3. (Level III evidence)
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