Forensic Toxicology

, Volume 30, Issue 2, pp 199–201

A curious case of body packing: impaction of cocaine capsules in a colostomy exit

Authors

    • II. Medizinische Klinik und Poliklinik, GastroenterologieKlinikum rechts der Isar, Technical University Munich
  • M. Martignoni
    • Chirurgische Klinik und PoliklinikKlinikum rechts der Isar, Technical University Munich
  • J. Säckl
    • Chirurgische Klinik und PoliklinikKlinikum rechts der Isar, Technical University Munich
  • N. Felgenhauer
    • II. Medizinische Klinik, Toxikologische AbteilungKlinikum rechts der Isar, Technical University Munich
  • F. Eyer
    • II. Medizinische Klinik, Toxikologische AbteilungKlinikum rechts der Isar, Technical University Munich
  • V. Tratzl
    • II. Medizinische Klinik und Poliklinik, GastroenterologieKlinikum rechts der Isar, Technical University Munich
  • R. M. Schmid
    • II. Medizinische Klinik und Poliklinik, GastroenterologieKlinikum rechts der Isar, Technical University Munich
  • S. von Delius
    • II. Medizinische Klinik und Poliklinik, GastroenterologieKlinikum rechts der Isar, Technical University Munich
Letter to the Editor

DOI: 10.1007/s11419-012-0139-4

Cite this article as:
Walter, B.M., Martignoni, M., Säckl, J. et al. Forensic Toxicol (2012) 30: 199. doi:10.1007/s11419-012-0139-4

Dear Editor,

Abdominal pain is a common symptom with a widespread bundle of possible causes from different medical disciplines. In some cases, foreign bodies are diagnosed as the reason for the complaints. In cities that are easily accessible by train or aeroplane, drug smuggling by body packing should be taken into consideration. Many different concealments have been previously described in the literature. In this short communication, we report an up-to-now unique case of body packing in a young man, who presented with an impaction of cocaine capsules in a colostomy space.

A 25-year-old male patient was admitted to our hospital due to alcohol intoxication during Octoberfest. The abdomen was soft with regular bowel sounds and absence of localized tenderness. Noteworthy was the existence of a colostomy, which was created after a knife attack 3 years ago. The colostomy exit appeared scarred and in a bad state of care. Further physical examination was unremarkable. Laboratory investigations were also unremarkable except for a high blood-alcohol level (2.7 g/l) and a positive screening for cocaine.

The patient complained of worsening abdominal pain during the hours following admission. The abdomen was still soft, but the colostomy exit now appeared swollen and painful. Ultrasonic examination was not possible due to pain. The patient agreed to an X-ray investigation of the abdomen. Abdominal film revealed several radiodense foreign bodies localized near the colostomy exit (Fig. 1). At this point, the patient confessed to being a drug courier using the colostomy exit as concealment for cocaine capsules. Due to severe abdominal pain and impaction near the colostomy exit, an emergency removal was necessary.
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Fig. 1

Abdominal X-ray with cocaine capsules visible near colostomy exit (rosette-like appearance, left lower abdomen)

A nonsurgical removal was attempted because the capsules were seen near the colostomy exit. The retrieval was performed in our toxicological intensive care unit with continuous measurement of vital signs. Due to the extremely scarred colostomy exit, only a gastroscope could be inserted (Fig. 2) and a small surgical incision was necessary before removal. In total, eight intact cocaine capsules (10 g each) (Fig. 3) were removed by using a snare. Further investigation showed no remaining foreign bodies. The patient was stable during the endoscopic procedure and postendoscopic supervision; he recovered well and left the hospital the following day. However, the prevailing question whether the colostomy exit was left for drug trafficking remained unanswered.
https://static-content.springer.com/image/art%3A10.1007%2Fs11419-012-0139-4/MediaObjects/11419_2012_139_Fig2_HTML.jpg
Fig. 2

Endoscopic view of the first cocaine capsule

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Fig. 3

Cocaine capsules after removal

“Body packing” is a term used to describe the practice of drug smuggling where drug packages are swallowed or pushed into an orifice to attain concealment. Substances carried are mostly heroin, cocaine, or amphetamines. Drug capsules usually contain 8–10 g each, which is a life-threatening dose in case of rupture. There is a report of up to 100 packets found in one courier [1].

For diagnosis of body packing, plain radiography or CT-scanning is suitable to establish the existence of foreign bodies [2, 3]. In some cases capsules are also visible by ultrasonic examination. The current approach for body packers is to allow a spontaneous evacuation of the drug containers [1, 4]. In case of complications (e.g., bowel obstruction) immediate retrieval of the capsules is needed [3, 5, 6]. There are several reports of endoscopic removal performed from the upper gastrointestinal tract (GIT), but none from the lower GIT [7, 8]. In patients presenting with massive hypertension, anxiety, dysrhythmia, generalized ischemia, and seizures, the possibility of a life-threatening cocaine overdose caused by rupture of cocaine capsules should be considered [1]. Patients presenting with these symptoms should be admitted to the intensive care unit immediately for further treatment. For acute cocaine poisoning, high doses of benzodiazepines are recommended, whereas β-adrenergic antagonists should be avoided [1]. Arterial blood gas analysis is useful, because patients show decreased pH levels as a result of lactate acidosis due to the ischemia induced by generalized vasospasm. Surgical removal is necessary immediately in cases of acute poisoning by capsule rupture [6].

Summarizing the case, the possibility of body packing should be considered in patients presenting with abdominal pain. Also, a colostomy exit can be used for concealment of drugs with a high risk of impaction. In general, a spontaneous evacuation of the drug capsules is the current approach, but in case of impaction, immediate removal is necessary. An endoscopic approach by an experienced endoscopist could be a viable mode of removal in special situations.

Copyright information

© Japanese Association of Forensic Toxicology and Springer 2012