European Radiology

, Volume 14, Issue 4, pp 736–742

Drug smuggling by body packing: what radiologists should know about it

Authors

    • Department of RadiologyZIR LKH Feldkirch
  • Karl Kofler
    • Customs Police
  • Wolfgang Oser
    • Department of RadiologyZIR LKH Feldkirch
Forensic Medicine

DOI: 10.1007/s00330-003-2091-5

Cite this article as:
Hergan, K., Kofler, K. & Oser, W. Eur Radiol (2004) 14: 736. doi:10.1007/s00330-003-2091-5

Abstract

Body packing is a distinct method for smuggling drugs. What radiologists need to know is discussed in this pictorial review. Radiologists are confronted with diagnostic imaging of body packers because of two main reasons: complications of body packing and identifying drug packets within the gastrointestinal tract. The standard examination used is plain X-ray of the abdomen in an upright and a supine position. Computed tomography is occasionally used but nevertheless described as a very accurate diagnostic tool. Ultrasound and MR imaging do not play an important role in that field. Depending on the purity of the drug, three different forms of attenuation have been described: hashish is denser than stool; cocaine appears similar to stool; and heroin has a gaseous transparence. The packets are of a round to oval form, usually of a particular uniformity and rarely confused with scybala if arranged like a pearl chain; therefore, plain X-ray is the method of choice to detect drug-filled packets within the gastrointestinal tract of body packers.

Keywords

DrugBody packingIntoxicationEmergencyX-ray

Introduction

Body packing is defined as smuggling drugs within the human body. Handmade or automatically produced packets are swallowed, rectally or vaginally inserted, and transported to western countries for commercially or own use [1]. Customs inspectors at airports and harbors of big cities and at the borders of the European Community are specially trained to recognize potential body packers. The simplest way to detect drug-filled packets in the intestine is plain X-ray of the abdomen [2]. For that reason radiologists need to know how to interpret X-ray films of possible body packers, of patients with symptoms of intoxication, and of people coming from abroad with signs of an ileus. With the approaching expansion of the European Community the outer borders are shifted to the east so that new duties and responsibilities are transferred to customs inspectors, forensic medical examiners, as well as clinicians and radiologists of the new members of the community; therefore, knowledge is demanded on the complications of body packing, how to detect and identify body packers, and how to treat them.

The aim of this article is to discuss the different drugs smuggled, how drugs are packed and hidden in the body, which diagnostic method is useful, what is the radiological appearance of drug-filled packets, and which complications radiologists have to be able to recognize.

Drugs, packets, and body packers

Commonly, there are three major drugs smuggled with body packing: cannabis products; heroin; and cocaine. Synthetic drugs, such as ecstasy pills/tablets and LSD (lysergic acid) platelets, are rarely found in body packers, probably due to the lower financial incitement. Smuggling hallucinogens, such as mescaline, a product of a Mexican cactus, and psilocybin, also known as magic mushroom, is absolutely rare in Europe.

Marijuana and hashish are two different products of the cannabis plant. Marijuana is made from the tips of the leafs and blossoms of the female cannabis plant and is usually used in Europe, United States, and Mexico. Hashish is a resin of the undersurface of cannabis leafs and is produced and marketed in the middle sea and Balkan countries. Depending on the country of origin, hashish is characterized by a bright, red, or black color.

Heroin is a chemical product of opium which is refined out of the milky juice of the poppy capsule. Usually, the heroin powder has a bright or white color, but depending on the admixture of substances, color and consistency may vary.

Cocaine usually is a white powder made out of the leafs of the coca plant. Sometimes it is pressed to a stony object with some crystalline enclosures. Crack is a chemical derivate of cocaine used for smoking in cigarettes or special pipes. It has a much higher and faster effect on the drug abuser than the powder.

Drug packets are hand made or mechanically produced. Condoms, latex, cellophane, and other synthetic materials are formed to balls or oval-shaped objects usually 2–4 cm in size. The swallowed packets are smaller than the rectally or vaginally inserted drug packets. Mechanically produced packets have a uniform shape, mostly round and 2 cm in diameter.

Different signs and a typical profile characterize body packers. Of drug couriers, 80% are presumed to be body packers [3]. When used as a drug courier by a drug organization body packers usually wear a shirt and jacket of better quality than the trousers or shoes are. They usually do not wear expensive watches or jewels and differ from business people by the way of conversation. Smugglers traveling as tourists usually do not have arrangements of tourist agencies, have no definite destination, and travel with too much cash (€ 500–1000). When traveling in airplanes the tickets are usually paid with cash. Body packers carry along with their luggage special utensils such as condoms, latex fingers and gloves, petroleum jelly, coconut oil for swallowing the packets, toilet paper, sprays and deodorants against bad smell after vomiting and flatulence, spasmolytics to reduce peristalsis of the intestine, and coal tablets to absorb drugs in case of packet rupture. Drug smugglers coming to the customs appear suspicious when using black sun glasses to conceal their red eyes and small pupils after drug abuse; some are extremely apathetic others nervous, i.v. drug abusers often wear shirts with long sleeves to hide the needle-puncture site. These are only some typical guiding principles for customs inspectors to figure out which people entering a country are suspected of smuggling drugs.

Radiological methods to investigate body packers

Plain X-ray film, Ultrasound, CT, and MRI are the most commonly used methods to examine people suspected of being body packers but also people coming with an acute abdomen to the emergency room. Ultrasound is a first-choice exam to detect free abdominal fluid and an ileus. Examining the bowel for small foreign bodies is problematic as the drug-filled packets may have a similar appearance to stool and air, and are characterized as an echogenic structure with a shadowing [2, 4, 5]. Computed tomography is without doubt the most exactly working method [4, 6, 7]. Geometrically formed structures localized within the small and/or large bowel positioned in a periodic order are a characteristic finding. With CT it is possible to measure the density of a suspect structure which may be indicative for a drug [8, 9]. The radiation risk, the effort, and the used time and resources are limiting factors using this method for examining each body packer, although its value has repeatedly been described for evaluating an acute abdomen [10, 11]. The MRI is of very limited value for detecting foreign bodies particularly when they are lacking of protons and are located within the moving and artifacts inducing bowel [8]. The most used and obviously reliable method for this scenario is the plain X-ray film of the abdomen in an upright and supine position [2, 7, 8, 9]. It is quickly done, radiation for the patient is low, it is well tolerated, and the detection rate for drug-filled packets is high. For those reasons plain X-ray film is the method of choice to obtain proof of smuggling drugs in asymptomatic body packers. In symptomatic people suspected of having a complication related to drug-filled packets, such as an ileus, bowel wall perforation, or drug-associated reaction, ultrasound is usually followed by a plain X-ray film and sometimes by an abdominal CT.

Form and size of drug packets

Form and size of the packets depend on the way how they are produced (handmade vs mechanically produced) and how they are brought into the body (orally or rectally inserted). Packets which are swallowed are usually smaller and around 2 cm in size and spherical in shape. Rectally inserted packets often have an oval form, are 4–6 cm long and 2–3 cm wide. A ball-like form of packets with a diameter of up to 5 cm is not rare [8, 9]. Mechanically produced packets have a very uniform shape, whereas handmade ones each look a little bit different each [1]. Condoms and latex is the preferred material for drug packets. Important for ingestion and rectal insertion is a very compact form of the packets (Table 1).
Table 1

Possible form, size, and arrangement of drug packets as detected on plain X-ray film of the abdomen. The presented data display the common findings. Variations may occur

Packets

Oral

Rectal

Mechanically made

Handmade

Form

Round

Oval/round

Uniform

Different

Size

<2 cm

2–6 cm

2–6 cm

2–6 cm

Arrangement

Many together

Single/few together

Usually many together

Usually few together

Radiological appearance of drug packets

Plain X-ray of the abdomen in an upright and supine position is the most used examination to detect drug-filled packets. A few papers report on the typical appearance of the different drugs depending on their density [6, 8, 9, 12]. Hashish is described to appear on the X-ray film as a very dense substance in comparison with stool; both are denser than water. Concerning these reports, cocaine should have an attenuation lesser than water, whereas heroin should look like air. In collaboration with the Austrian Customs Police our experiences and experiments show that the radiological density of a drug depends very much on the composition with other substances or on its grade of purity (Fig. 1). Heroin, hashish, and cocaine may appear very similar to each other, e.g., being much denser than fecal balls on the plain X-ray film. On the other hand, heroin packed as a powder may have an attenuation like air, and cocaine powder may show a density like water; therefore, in case of using CT the measured Hounsfield units of a drug-filled packet in the bowel may differ to that what has been described by Wackerle et al. [8]. According to that report hashish has a density like bone, cocaine is less dense than fat, and the Hounsfield units of heroin are situated between fat and air (Table 2). Moreover, CT has been described to have a higher potential to detect drug packets than plain X-ray [4].
Fig. 1

a Different compositions of heroin (first row) and cocaine (second row). Pressed hashish chips, ecstasy tablets, and Thai pills are shown in the third row. b Plain X-ray film of the drugs shown in a. Heroin powder is of very low density like air. Cocaine powder is a low-attenuating substance, whereas cocaine stones are characterized by a very high density with some small crystalline enclosures

Table 2

Data presented by Wackerle et al. [7]

Drugs

X-ray density

CT density

Variability X-raya

Heroin

Air

−520 HU

Air–stool

Cocaine

Less than water

−219 HU

Air, less or more than stool

Hashish

More than stool

700 HU

More than stool

aOwn experience with different drugs, depending on the purity of or admixture to a substance

As described above, the size and form of the foreign bodies depend on the way drug-filled packets have been produced and how they have been inserted into the body. Usually rectally dispensed packets are much larger than orally swallowed packets. Handmade packets may differ to each other as shown in Fig. 2. They can have a round, oval, or banana-shaped form. There has been described a so-called double-condom sign [4, 12], characterized by a very thin air-filled interface or halo between a high density substance and the surrounding tissue. On the other hand, the wall of drug-filled packets made out of condoms, latex, or other synthetic material has a very dense edge, and are therefore easily detectable as a foreign body (Fig. 3). Lesions shaped like big air bubbles in the rectum and sigmoid should be suspected of being drug-filled packets (Fig. 4), but also in cases when many small, round, and similarly appearing lesions are positioned in a row independent of their density (Fig. 5). The number of packets may vary significantly between a singular packet and up to 200 foreign bodies [13].
Fig. 2

a Handmade packets including different drugs. b Plain X-ray film of some packets shown in a, located on the surface of the abdomen of a volunteer in a supine position. Cocaine stone and pressed cocaine powder composed of another substance are easily detectable because of high density. Pure cocaine powder and ecstasy tablets cannot be depicted with certainty, and heroin powder is just perceptible

Fig. 3

a Female body packer with four condoms filled with cocaine. Umbilical Piercing. b A magnification of the pelvic region of the image shown in a. Homogenously appearing packets with almost the same attenuation as stool. The surface of the condoms is characterized by a very bright edge. Sometimes body packers use two condoms or there is little space between the substance and the condom so that a thin air-filled gap creates the so-called double-condom sign (not shown in this figure)

Fig. 4a, b

Five handmade spherical, heroin-filled packets rectally inserted in a male body packer. The concealed drug is of very low density like air and could be misinterpreted as bowel gas if the packets would have a more irregular shape

Fig. 5a, b

Hashish containing foreign bodies with ball-like shape and rectally inserted in a male body packer. Hashish is of higher density than stool and together with the arrangement of the packets it can hardly be confused with scybala

Ultrasound does not have the same sensitivity to detect foreign bodies in the small or large bowel. Packets appear as echogenic lesions with a geometric or regular shape in a fluid-filled bowel [4]. Those packets integrated within scyballa or situated between stool and gas are usually missed with ultrasound [2].

Magnetic resonance imaging does not have any diagnostic value for the detection of drug packets in the bowel. Wackerle et al. [8] found no characteristic difference in signal intensity between the tested drugs. As there are no free protons and the packets are tight against water, packets should appear as geometrically formed bodies without any signal in a fluid-filled bowel provided the bowel has been immobilized with spasmolytics. The MRI is diagnostically useless in an air-filled bowel with normal peristalsis.

Discussion

The aim of this article is to make radiologists aware of thinking of foreign bodies in young patients coming into the emergency room with an acute abdomen after arriving from a journey through an exotic country, and when being confronted with a person suspect of being a body packer. Radiologists should know how drug packets may look with different radiological tools. The aim of that knowledge is to identify a person as a body packer, to protect a body packer against the danger of a packet rupture, and to recognize mechanical or systemic complications induced by the drug-filled ingested packets.

Before examining a person presented by a customs inspector, radiologists have to check the medicolegal situation in their country, i.e., if it is possible to use X-ray, CT, or MRI without a medical indication. This may be different in countries of the European Community. In some countries the suspicious person has to agree to possibly harmful examinations. Other countries allow the necessary exams in order to convict a body packer who has been suspected by a customs officer and/or with a judicial injunction; therefore, the legal situation should be clear in advance.

There are three main reasons why radiologist are confronted with the diagnosis of body packing: suspecting person to be a drug courier; intoxication; and mechanical complications through the packets. Special signs often indicate that persons entering a country will be suspected of being a body packer by customs inspectors. Instant hair and/or urine tests may confirm drug abusers serving as drug couriers [3], but these tests need not be positive [14, 15]. Drug couriers smuggle for reasons other than drug abuse and dependence, such as for earning a lot of money or simply because of ignorance or trust in another person. Recently, there has been a report about children being misused as body packers [16] so that it becomes progressively difficult to filter people passing border-crossing points.

Intoxication after packet rupture [17] may be a challenge for a correct diagnosis if there are no attendants with the intoxicated person who could give some information, or if there are no extracorporal signs of being a drug abuser. Certainly, the risk to become intoxicated as a drug courier seems to be low in comparison with the number of body packers [3].

Obstruction, bowel wall perforation, and peritonitis are the most common physical complications of body packing [1, 2, 4, 12]. Radiologists should be aware that bowel obstruction with all consecutive complications may be caused by foreign bodies. Careful reading of plain X-ray films of the abdomen and a high skill in doing ultrasound is needed not to miss the underlying cause of an acute abdomen. If there exists any suspicion of drug packets in the intestine, CT may be used as a further diagnostic tool [8]. Radiologists have to remember always that the aforementioned complications may lead to death [18].

Occasional reports exist on the detection of drug packets with ultrasound [2, 4, 19], MRI [8], and contrast study of the bowel [20]. In a very recent report Meijer and Bots describe ultrasound as a very sensitive method in a preselected patient population [5]. Nevertheless, the most used diagnostic method for examining persons suspected of being body packers is plain X-ray film of the abdomen in an upright and supine position. Karhunen et al. [21] describe a high sensitivity and specificity for this method and had in their patient group a correct positive rate of 11% and correct negative rate of 84.2%. The false-positive cases were caused by constipation which is a common problem in females, whereas the false-negative rate had a very heterogeneous background: inexperienced radiologist; marijuana; packets with only few wrappings; aluminum-coated packets; and machine-packed drugs. Computed tomography is described to be the most sensitive method, but it is definitely not the first-choice diagnostic tool [4, 7, 8, 19].

Although there has been described a special appearance and density of the different drugs for plain X-ray and CT [8, 9], the amount of attenuation is much more dependent on the purity of a substance or the admixture to a drug. Radiological appearance is defined by the way packets are formed, produced, and inserted into the body. Although complications with body packing are rare, radiologists should keep in mind that patients coming to the emergency room with an acute abdomen or an intoxication are potential body packers particularly when they are young and have just returned from a journey through exotic or drug-producing or drug-selling countries [1, 3, 23].

Conclusion

There are several facts of which radiologists should be aware:
  1. 1.

    Young patients with an ileus are potential body packers.

     
  2. 2.

    Intoxication may be caused by rupture of an ingested drug packet.

     
  3. 3.

    Plain X-ray of the abdomen is the most important radiological tool to detect packets.

     
  4. 4.

    Special radiological signs point to drug packets in the bowel.

     
  5. 5.

    The value of a correct radiological diagnosis is to identify a body packer, to prevent body packers from possible complications, and to figure out the cause of complications induced by drug packets.

     

Copyright information

© Springer-Verlag 2004