CASE 9308 Published on 04.06.2011

Packets filled with heroin in the oesophagus and colon

Section

Chest imaging

Case Type

Clinical Cases

Authors

Bettini G, Spallanzani S, Orsitto E.

Patient

23 years, male

Categories
Area of Interest Thorax, Oesophagus, Abdomen ; Imaging Technique Digital radiography, CT
Clinical History
A 23-year-old man, with no medical or surgical history, presented to the emergency room with dyspnoea and agitated.
Imaging Findings
Radiographic imaging reveals an ovoid opaque area, at the C6-C7 level, with the longest diameter of approximately 3.5cm. These radiographs show the air column of airway displaced by an ovoid well described radiodense lesion (Fig.1; Fig.2). There are also numerous radiodense lesions mainly oval-shaped in the intestine (Fig.6; Fig.7).
CT confirms the presence of an ovoid foreign body (vertical diameter of 30 mm, transverse diameter of 28 mm and anterior-posterior diameter of 20 mm) within the proximal third of the oesophagus (Fig.3, Fig.4, Fig.5).
Discussion
“Body-packing”is a means of international drug-smuggling.
It involves packets containing drugs by either swallowing or inserting the packets rectally or vaginally[3]. Various materials -latex-condoms, cellophane, pig intestines- can be used for wrapping.
Abdominal-radiograph is the initial imaging method of choice. It may reveal the "tic-tac-sign" (multiple oblong-shaped-opacities); the "rosette-like" sign at one end of the packet (the air trapped in the knot where a condom is tied) and the "double-condom-sign" (a rim of air between layers of latex, when a double-wrapped condoms is used)[2;3].
Ultrasonography leads to a high rate of false positive and false negative scans[3]. CT is more sensitive than radiography and may demonstrate packages within the bowel not identified with radiography[2;3].
The appearance of each drug depends on its density: hashish appears denser than stool, cocaine similar to faeces and heroin demonstrates a gaseous transparence[2;3]. The radiological density of a drug depends also strongly on its grade of purity. Heroin, hashish and cocaine may appear very similar to each other. Hashish has a density like bone, cocaine is less dense than fat and the Hounsfield-units of heroin lie between fat and air[4].
Constipating agents (diphenoxylate, loperamide) are frequently used by smugglers, after haning swallowed the packets, in order to mask them[2].
The person who ingests or inserts drug-filled-packets into his or her rectum or vagina, in order to get across borders without being detected is called “mule” or “body-packer”[1]. On the other hand, the person who ingests drugs urgently, is a “body-stuffer”. He is a drug dealer or a drug abuser, who swallows illegal drugs fast because of no time to pack the drugs carefully, in an effort to avoid being arrest[5].
Early surgery intervention was formerly recommended for asymptomatic body-packers, because of the high rate of rupture of packets with primitive wrapping. The current approach is conservative therapy with bowel irrigation, close observation, and careful monitoring in the hospital[2]. Our patient presented dyspnoea and he was agitated, because of his difficulty in breathing, until the spontaneous passage of the foreign-body in the stomach.
The main medical complications are bowel obstruction and acute drug toxicity caused by rupture of condoms. There have been reports of sudden deaths[1]. In such an emergency the priority is to maintain airway patency and administer naloxone.
Differential Diagnosis List
Packets filled with heroin in the oesophagus and colon.
Other foreign bodies
Packet filled with cocaine or other drugs
Final Diagnosis
Packets filled with heroin in the oesophagus and colon.
Case information
URL: https://www.eurorad.org/case/9308
DOI: 10.1594/EURORAD/CASE.9308
ISSN: 1563-4086