Radiological features of body packers: An experience from a regional accident and emergency department in close proximity to the Hong Kong International Airport

Abstract

Background: Body packing is a frequently used method for drug trafficking. Local information about the clinical and radiological features of body packing is lacking. Objectives: To evaluate the radiological features of body packers presenting to a hospital near to the Hong Kong International Airport and to compare the radiological features of solid form versus liquid cocaine. Methods: This was a retrospective cohort study. Medical notes of 269 suspected body packers, presenting to the Accident and Emergency Department of North Lantau Hospital under the detention by the law enforcement personnel from 1st January 2015 to 28th February 2017, were reviewed. The radiological features of body packing were retrospectively evaluated. Results: Sixty-nine cases were confirmed body packers radiographically. Majority of them (81%, 56/69) were cocaine packers. Powder form cocaine (67%, 49/69) was the most popular drug packed, followed by liquid cocaine (15%, 10/69). There was a trend of increasing incidence of liquid cocaine packers. The classical `double condom', `tic tac' and `halo' signs were present in 94%, 72.5% and 42% of cases with radiologically confirmed body packing respectively. The `rosette' sign was only identified in 1 case. Three new radiological signs, the `bag of eggs', `lucent triangle' and `black crescent' sign, were suggested to aid identification of drug packets. The classical `tic tac' sign was absent in all liquid cocaine packing cases (p<0.05). The liquid cocaine packets appeared irregular with indistinct border in majority of cases (p<0.05). The solid form packets were mostly opaque to faeces while liquid cocaine had variable density (p<0.05). Most solid form packets had homogeneous content which was in contrast to the heterogeneous content in liquid cocaine (p<0.05). Conclusion: Failure in detecting drug body packing may result in medicolegal consequences. Emergency physicians need to be aware of subtle radiological signs of liquid cocaine packets in the plain abdominal radiography.

Clinical presentation, diagnosis and management of aerodigestive tract foreign bodies in the adult population: Part 1

“…In the majority of the cases, the narcotics are usually solid drugs; however, recently a novel method of smuggling has emerged where the body packers ingest packages stuffed with liquid cocaine. 43 , 44 …”

“… 43 , 44 The presence of one or more well-defined opacities in the stomach, small or large intestine, that are not suggestive of gastrointestinal contents, should raise suspicion for body packing. Other ancillary imaging findings or signs that have been described are: (1) the ‘double condom sign’ – the presence of radiolucent air crescent trapped between multiple layers of packing surrounding each packet; (2) the ‘tic-tac’ or ‘bag of eggs’ sign – refers to the presence of several homogeneous radiodense oval or round shaped structures with sharp margins and clear air-substance interface ( Figure 11a ); (3) the ‘parallelism sign’ – firm narcotic packs aligning parallel to each other in the intestinal lumen; (4) the ‘rosette sign’ – refers to air trapped in the knot of the drug packet; (5) the ‘halo sign’ – a complete rim of blurred lucency surrounding the drug packet 43 , 44 ; (6) the ‘black crescent sign’ – a crescent of air around the drug packet; and (7) the ‘lucent triangle sign’ – representing air in the interface between drug packets or with the bowel wall. The ‘double condom’ and ‘halo’ signs that have traditionally been used for detecting packets containing solid drugs, are also effective in detecting liquid cocaine.…”

“…In the majority of the cases, the narcotics are usually solid drugs; however, recently a novel method of smuggling has emerged where the body packers ingest packages stuffed with liquid cocaine. 43,44 The various imaging modalities available for identifying body packing are plain abdominal radiography, ultrasound, CT and MRI. Of these, the first two are the most commonly used screening tools, with plain abdominal radiography being the most widely used test because of its lower cost and ease of availability.…”

“…In addition, packets with liquid narcotics tend to be irregular, with ill-defined borders and show variable density unlike solid drugs that are often opaque to faeces (Figure 11b). 44 Common mimickers for drug packets on conventional radiography include hardened faeces (faecaloma or scybala), intestinal air, calcifications and other foreign materials. 43,44,45 On ultrasound, packages containing solid drugs appear as multiple, ovoid, immobile, smooth contoured echogenic masses within the bowel lumen, demonstrating strong posterior acoustic shadowing.…”

“…44 Common mimickers for drug packets on conventional radiography include hardened faeces (faecaloma or scybala), intestinal air, calcifications and other foreign materials. 43,44,45 On ultrasound, packages containing solid drugs appear as multiple, ovoid, immobile, smooth contoured echogenic masses within the bowel lumen, demonstrating strong posterior acoustic shadowing. Moreover, reverberation artefacts may be seen behind the packets secondary to trapped air in the sheaths.…”