Body packing and body stuffing: Review of a case study and proposal for a decision algorithm

Objective: Body packing and stuffing represent an emergent problem worldwide with associated risks including acute intoxication and bowel obstruction. In recent years mortality and morbidity have progressively diminished due to an appropriate clinical management and a better packaging of substances, thus leading to a more conservative approach. Methods: From January 2000 to August 2013 we observed 82 patients with diagnosis of suspected packing (n 48) or stuffing (n 34). Seventy-six patients agreed to perform radiological confirmation (X-Ray 15, CT 23, X-Ray+CT 39). Once admitted,the patients underwent monitoring, oral administration of polyethylene glycol (PEG) and qualitative and quantitative check of retrieved packs. Moreover, 73 patients were radiologically checked to confirm pack elimination. Results: 22 patients (9 packers,13 stuffers) showed signs/symptoms of mild to moderate intoxication. In 3 cases the surgical pack removal was necessary (1 for severe intoxication from cocaine, 1 for gastric storage and 1 for bowel obstruction), while 1 patient underwent the endoscopic removal for prolonged pack retention at gastric level over 5 days. One patient presented with heroin overdose was misleadingly sent to the surgeon as CT-scan falsely attributed positive images to heroin-containing wrappings. The average hospital stay was similar for packers and stuffers (25 hours, range 1-164 h). Conclusion: Body drug concealment is still a behavior that can pose life-threatening risks, requiring a multi-disciplinary diagnostic and therapeutic approach. So far, no guidelines or standardized procedures exist for the management of such patients. However, our results confirm the appropriateness of a conservative approach in most cases, implemented with a surgical procedure only in severely ill patients (leaking packages, bowel obstruction). The CTscan resulted to be more sensitive and specific vs X-Ray imaging in defining both pack assumption and elimination monitoring. Considering our experience and the literature (1), we propose to adopt in these patients an algorithm in order to optimize management, hospital stay duration and complete pack elimination. (1) Mandava N, Chang R, Wanget J, et al. Establishment of a definitive protocol for the diagnosis and management of body packers (drug mules). Emerg Med J 2011; 98-101.