1. BODY PACKAGING AND BODY STUFFING:
REVIEW OF OUR CASE STUDY AND PROPOSAL FOR A DECISION-MAKING ALGORITHM
Gambassi F1, Galli V2, Missanelli A2, Bertieri L3, Pacileo I3, Quaranta MR3, Mannaioni G2,3, Masini E2,3
Poisoning Control Center1, Unit of Toxicology2 and Department of NEUROFARBA3, University of Florence-Azienda Ospedaliero Universitaria Careggi, Firenze, Italia
Table 1
1. INTRODUCTION
Body packing and stuffing, the concealment of illegal substances in a person's body with the aim of smuggling or concealing them from the police, respectively, 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 illicit substances, thus leading to a more conservative approach.
EFFECTIVENESS OF RADIOLOGICAL DIAGNOSTIC TECHNIQUES (X-RAY AND CT SCAN) IN BODY PACKERS TO CONFIRM PACKETS ASSUMPTION AT HOSPITAL ADMISSION.
X-Ray
CT-scan n
% of total exhams
True Positive (TP) 33
97.1 27 90
True Negative (TN) 2
6.7
False Positive (FP) 1
3.3
False Negative (FN)
2.9
2. OBJECTIVE
We retrospectively evaluated, clinical aspects, decontamination procedures, diagnostic imaging and treatment algorithm in a serie of consecutive 82 subjects admitted in our Unit from January 2000 to August 2013 with diagnosis of suspect packing (n 48) or stuffing (n 34).
3. CASE SERIES
Patients were submitted to radiological confirmation (X-Ray, CT-scan). Once admitted, the patients underwent vital signs monitoring, oral administration of polyethylene glycol (PEG) and qualitative and quantitative check of retrieved packs. Moreover, some patients were radiologically checked to confirm pack elimination when needed.
Table 2
EFFECTIVENESS OF RADIOLOGICAL DIAGNOSTIC TECHNIQUES (X-RAY AND CT SCAN) IN BODY STUFFERS TO CONFIRM PACKETS ASSUMPTION AT HOSPITAL ADMISSION.
X-Ray
CT-scan n
% of total exhams
True Positive (TP) 4 21 15
71.5
True Negative (TN) 5 19
False Positive (FP) 1*
5.3 2
9.5
False Negative (FN)
10**
52.7
*CT-scan showed a True Negative
**CT-scan demonstrated 7 True Positives
4. RESULTS
Radiological diagnostic techniques (19 X-Ray; 12 CT-scan; 15 X-Ray + CT-scan) confirmed packets swallowing in 45 out of 48 suspected body packers (BP). X-Ray and CT-scan had similar effectiveness in confirming assumption at hospital admission (100% and 96% positive predictive value _ppv_ for X-ray and CT-scan, respectively) (Table 1), although CT-scan was more effective to determine packets precise localization and number. Negative predictive value _npv_ was not determinable for X-ray (0 TN) and 100% for CT-scan.
Radiological diagnostic techniques at hospital admission were also performed for body stuffers (BS) (9 X-Ray, 10 CT-scan, 11 X-Ray +CT-scan) showing a better ppv and npv of CT-scan compared to X-Ray in these patients (80% and 88% ppv, 33.3% and 66.6% npv for X-ray and CT-scan, respectively) (Table 2).
PEG was successfully administered to 57 confirmed patients (41 BP, 16 BS) thus obtaining a complete packets rectal elimination. Confirmed BP and BS who refused PEG therapy (4 and 4, respectively), eliminated the packets naturally (Table 3).
28 patients (8 BP, 20 BS) showed signs/symptoms either related to mild acute intoxication or to chronic substance abuse. In 4 BP the surgical/endoscopic packs removal was necessary for severe cocaine intoxication, gastric retention, bowel obstruction and prolonged packs gastric retention, respectively (Table 3). One patient (false positive BS) suffered heroin overdose and was misleadingly sent to the surgeon as CT-scan falsely attributed positive images to heroin-containing wrappings. The mean average hospital stay was similar for packers and stuffers (29.4 vs 23.2 hours) (Table 3) . Finally, in BP CT-scan was more reliable than X-Ray in confirming packets decontamination (86% and 100% npv for X-ray and CT-scan, respectively) (Table 4).
Table 3
CLINICAL ASPECTS OF SUSPECTED BODY PACKERS AND STUFFERS
Cases (n)
DRUG
(n)
n of REFERRED PACKS
(min – max)
DECONTAMINATION
TECHNIQUE
MEAN HOSPITAL
STAY
(hours)
SYMPTOMATIC
PATIENTS
n + cause of symptoms
SURGICAL
REMOVAL
SUSPECT
PACKERS: 48
28.5 12
CONFIRMED 45
COCAINE (31)
UNKNOWN (5)
THC (4)
HEROIN (3)
HER. + COCAINE (1)
COCAINE +THC (1)
3-193
1-77
2-199
3-116 6 4
PEG 41
REFUSE 4
29.4
3 MILD COCAINE INTOXICATION
2 ABDOMINAL PAIN
1 NAUSEA
2 OPIOID WITHDRAWAL SINDROME
1 SEVERE COCAINE INTOXICATION*
1 GASTRIC RETENTION PACKS*
1 BOWEL OBSTRUCTION*
1 PYLORIC STOP** *3
**1 (Endoscopy)
NOT CONFIRMED 3 -
PEG 1
REFUSE 2
12.6
STUFFERS: 34
23.2 21 20
HEROIN (10)
COCAINA (9)
THC (1)
1-9
1-7
PEG 16
23.1
8 OPIOID WITHDRAWAL SYNDROME
1 MILD OPIOID INTOXICATION
3 SUPRAVENTRICULAR TACHYCARDIA
1 CHEST PAIN
1 ANXIETY
PEG 3
REFUSE 9 28
3 OPIOD WITHDRAWAL SYNDROME
2 SUPRAVENTRICULARTACHYCARDIA
FALSE POSITIVES 2
(5-20)
1 SEVERE OPIOID INTOXICATION***
1***
***CT: 20 images of foreign bodies (aliment fragments)
5. CONCLUSIONS
Our results confirm:
the appropriateness of a conservative approach in most cases, implemented with a surgical procedure only in severely ill patients (leaking packages, gastric packets retention, bowel obstruction);
the effectiveness and safety of PEG in decontaminating patients;
CT-scan showed a better positive (ppv) and negative (npv) predictive value vs X-Ray imaging in defining pack assumption in BS and elimination monitoring in BP. Moreover, CT-scan was more effective to determine packets precise localization and number in both BP and BS;
considering our experience and the revision of the literature (1-3), we propose to adopt in these patients an algorithm in order to optimize management, hospital stay and complete packets elimination.
Table 4
EFFECTIVENESS OF RADIOLOGICAL DIAGNOSTIC TECHNIQUES (RX AND CT SCAN) IN BODY PACKERS TO CONFIRM PACKETS ELIMINATION AT HOSPITAL DISCHARGE.
X-Ray
CT-scan n
% of total exhams
True Positive (TP) -
True Negative (TN) 6
87.2 21
100
False Positive (FP) 1
12.8
False Negative (FN)
REFERENCES:
Beckley I et al Can J Surg, Vol. 52, No. 5, October 2009, ;
Booker RJ et al Emerg Med J May;26(5):316-20;
Mandava N et al Emerg Med J Feb;28(2):
XXXIV International Congress of the European Association of Poisons Centres and Clinical Toxicologists May 2014, Brussels, Belgium