Body packing or internal concealment used by drug dealers to smuggle illicit substances, puts the body packer at risk of both imprisonment and death. We report our experience over a 4 year period from January 1996 to December 1999 of suspects presenting to our hospital (the largest series in Europe). A total of 572 cases were assessed radiographically and 180 were shown to be carrying foreign bodies. The commonest reasons for admission were suspected overdose or gastrointestinal obstruction. Thirty-six cases were admitted, of whom 7 required surgical intervention. No deaths occurred. Of all people detained for smuggling by internal concealment into Britain during this period, 27% were seen in our hospital. These cases may present alone or escorted by Her Majesty's Customs and Excise personnel, and one must be aware of this possibility even when situated away from a port of entry.
The incidence of smuggling and transporting of illegal drugs by internal concealment, also known as body packing, is increasing in the Western world. The objective of this study was to determine the outcome of conservative and surgical approaches in body packers.
Materials and methods
Clinical data on body packers admitted to our hospital from January 2004 until December 2009 were collected. The protocol for body packers required surgery when packets were present in the stomach for >48 h. Outcomes of the conservative and surgical group were assessed and analyzed. Morbidity and mortality were assessed in body packers with drug packets present in the stomach for <48 h and in those with gastric packets for >48 h.
During the study period, more body packers were treated conservatively. Mortality was 2% in all patients and was due to intoxication. There were no significant differences of mortality, hospital admission time, and ICU admission time in the compared groups with drug packets in the stomach for less or >48 h. In 24% (4/17) of the patients with bad package material, a ruptured drug packet was found during surgery. This resulted in death in only one patient.
Drug packets in the stomach for >48 h are not an indication for surgery. We recommend that surgery should only be performed in body packers with signs of intoxication or ileus and reserve conservative treatment for all other patients.
Body packer; Conservative; Surgery; Treatment
Body packing is described as using the abdominal or pelvic cavity for concealing illegal drugs. Leakage from the packets may cause catastrophic effects on smugglers and medical history is not reliable in these patients. Moreover, new sophisticated smuggling techniques make it imperative that radiologists and emergency physicians understand and familiarize themselves with the different radiological manifestations of ingested drug packets. Currently, there is no gold standard for imaging patients suspected of body packing; nevertheless, computed tomography (CT) seems to be the best modality for packet detection and unenhanced CT without bowel preparation is a reliable technique for detection of ingested packets. On abdominal radiography, packets may be visualized as oval or round radiopaque foreign bodies surrounded by a gas halo. In the literature, sensitivity of abdominal radiography is reported from 74% to 100%. Visualization of the drug packets may be strikingly hampered by administration of oral or intravenous contrast medium in abdomino-pelvic CT; hence, contrast-enhanced CT does not seem to be a suitable modality for searching the ingested packets in suspicious smugglers.
Pelvis; Abdomen; Radiography, Abdominal; Tomography, X-Ray Computed
International smuggling of cocaine by internal concealment is a serious and growing problem. People who engage in this practice are commonly referred to as body packers or mules. The most serious risks associated with body packing include intestinal obstruction and death from cocaine intoxication. These patients were previously managed primarily by surgical retrieval. This was associated with significant mortality due to rupture of poorly constructed cocaine packages. More recently, conservative management using whole bowel irrigation with polyethylene-glycol (Klean-prep Norgine) has been shown to be safe for most patients. To date, however, a consistent approach for the management of these patients has not been established.
We retrospectively reviewed the case notes, prescription charts and radiological investigations of all body packers admitted to our unit between 2000 and 2005, concentrating on initial management, complications and outcome.
We identified 61 patients for inclusion. Of these, 56 were managed conservatively with a selection of aperients and laxatives. Six patients were treated successfully for cocaine toxicity and 5 required surgical retrieval of cocaine packets.
Our results confirm the safety of a conservative approach. Based on our experience and a review of the literature, we have devised a treatment protocol to reduce the risk of complications and the length of stay in hospital.
Body packing is used for international drug transport, immediate drug concealment during a police searching or introducing drugs inside prisons. Despite the high level of specialization of dealers who have started to manufacture more complex packs, up to 5% of patients could develop intoxication due to pack rupture. Bowel obstruction is another acute complication.
A 27-year-old black male patient was sent to the hospital by court order for clinical evaluation and toxicological examination. The patient was conscious, oriented, had good color, normal arterial pressure and heart rate, and no signs of acute intoxication. Abdominal examination revealed discrete pain upon deep palpation and a small mass in the left iliac fossa. A plain abdominal radiograph revealed several oval structures located in the rectum and sigmoid. Fasting and a 50 g dose of activated charcoal every six hours were prescribed. After three days, the patient spontaneously evacuated 28 cocaine packs.
Adequate clinical management and prompt identification of potential complications are of fundamental importance in dealing with body packing.
OBJECTIVE: To evaluate a metal detector to diagnose swallowed radio-opaque metal foreign bodies (MFBs) in children, and whether they can detect non-radio-opaque MFBs. METHODS: In a prospective study, 231 children, who presented to the accident and emergency department with a history of swallowing MFBs, were evaluated by the metal detector as well as radiography to confirm and locate the presence or absence of MFBs. RESULTS: A definite history of swallowing a MFB by the child was given by 186 (81%) parents. The metal detector located MFBs in 183 children and radiographs confirmed radio-opaque MFBs in 181. In the remaining 45 (19%), when swallowing was suspected and not definite, both metal detector and radiography confirmed the presence of a MFB in only four. CONCLUSION: A high detection rate of swallowed MFBs was observed in this study, using a metal detector. It is also of value to detect non-radio-opaque MFBs like aluminium. The detection of MFBs is high when the history of swallowing is definite.
OBJECTIVE: A pilot study to assess whether modern metal detectors can reduce unnecessary radiation in searching for ingested metallic foreign bodies. METHODS: Over a one year period, 20 children presenting to an accident and emergency department with suspected metallic foreign body ingestion were studied. Using an Adams Electronics AD15 metal detector, the radiographer recorded the location of metallic foreign bodies on a pictorial representation of neck, chest, and abdomen. The child then had plain radiographs of abdomen, chest, and neck in sequential order until the foreign body was located. RESULTS: In seven cases neither metal detector nor radiography revealed a foreign body (true negatives). In the remaining 13 cases where metal detection was positive, subsequent radiography or faecal search was also positive (true positives). The 13 foreign bodies were coins (8), gold ring (1), ball bearing (1), screw (1), staple (1), and washer (1). All were in the stomach or proximal small bowel on radiography except for one coin in the right iliac fossa. CONCLUSIONS: The detector can demonstrate ingested metallic foreign bodies reliably in children, thereby reducing unnecessary irradiation.
Nasal bleeding is a frequent problem for patients receiving anticoagulant agents.
Most cases are successfully managed with anterior or posterior nasal packing.
However, the complications of nasal packing should be always considered. We
report the case of a 78-year-old man with Alzheimer’s disease who was
treated for anterior epistaxis with anterior nasal packing using three pieces of
antibiotic-soaked gauze. Two days later, the patient was admitted to the
emergency department in respiratory distress. A chest x-ray demonstrated
atelectasis of the right lung. During an examination of the nasal cavities, the
nasal packing was removed, and one of the gauze pieces was missing. The patient
underwent rigid bronchoscopy, and the missing gauze was found to be obstructing
the right main bronchus. The patient’s respiratory function improved
considerably after removal of the foreign body. It is assumed that gauze packs
should be used with caution in patients with an impaired level of consciousness
and neurodegenerative diseases.
epistaxis; nasal packing; aspiration; Alzheimer’s disease; cough reflex
Swallowed foreign bodies encounter a major problem especially in children, but fortunately they mostly do not cause any related complication and are easily passed with the stool. In this paper, an interesting journey of a needle is presented. A 20-year old female admitted to our emergency service after she had swallowed a sewing machine needle, which is initially observed in the stomach in the plain abdominal radiography. During the follow-up period, the needle traveled through bowels, and surprisingly was observed in the left lung on 10th day of the follow-up. It was removed with a thoracotomy and pneumotomy under the fluoroscopic guidance. The postoperative period was uneventful and the patient was discharged from the hospital on the day 5. We also review the literature on interesting extra-abdominal migrations of swallowing foreign bodies.
Foreign body; migration; pneumotomy
Iran is one of two main target markets for tobacco smuggling in the WHO's Eastern Mediterranean Region. The Iranian government has a local tobacco monopoly but there is high demand for international brands. Informal reports show about 20% of cigarette consumption is smuggled brands. This pack survey study is the first in Iran to gather validated information on use of smuggled cigarettes.
A randomized cross-sectional household survey in Tehran in 2008–2009 of 1540 smokers aged 16–90 (83% men) was performed, including interviewer checking of cigarette packs.
In all, 20.9% of cigarettes and 6.7% of domestic branded cigarettes were smuggled. A total of 60.1% of smokers preferred foreign cigarettes. There was no significant difference between consumption of illegal cigarettes by sex. (Fisher exact test p=0.61) Use of smuggled cigarettes was higher among younger smokers (p=0.01)
Use of illegal cigarettes is high. Tobacco control laws outlawing their sale are not being enforced.
Cigarette; smuggling; Iran; Nicotine products
Intentional ingestion of foreign bodies is common in psychiatric patients and prison inmates. Timing of endoscopy for ingested foreign bodies varies and depends on the type and location of the foreign body in the gastrointestinal tract. We present the case of a 26-year-old man who was brought from a correctional facility after confessing to have swallowed a few shower curtain hooks. Abdominal X-ray done in the emergency room revealed multiple foreign bodies in the stomach. An upper endoscopy was done in the emergency room with the use of an overtube. The first metal piece was caught by a snare and removed with the endoscope. All other foreign bodies which were present on the abdominal X-ray could not be visualized initially as there was retained food in the stomach. After multiple attempts, four other foreign bodies were found and each one was caught by the forceps and then the scope was removed with the forceps holding the foreign body. There was an additional foreign body in the right mainstem bronchus. The patient had coughed up the foreign body and swallowed it into the gastrointestinal tract. A computed tomography scan of chest and abdomen was done for evaluation, which showed the foreign body in the cecum. To our knowledge, this is the first case report of a patient intentionally transferring a foreign body from one organ system to another. Colonoscopy was done and the foreign body was removed rectally with a snare without any complications.
Foreign bodies in the stomach; Bronchus; Colon
Penetrating hand injuries are common and improper assessment can result in missed foreign bodies. These bodies can result in a wide range of complications.
The aim of our study was to study the profile of patients reporting with missed foreign bodies in the hand.
Materials and methods
All the cases treated in the Department of Surgery, Sheri Kashmir Institute of Medical Sciences (medical college), Kashmir, for missed foreign bodies in hands from June 2003 to May 2009 were studied retrospectively.
A total of 61 cases with missed foreign bodies of different nature were treated over the period of six years. Wooden splinters were the most common foreign bodies missed. Preoperative localization was accomplished with plain radiographs and ultrasonograms. Most of the cases were treated on outpatient basis.
Foreign bodies should be suspected and ruled out in all cases of penetrating injuries of hands. Missed foreign bodies need to be removed after proper localization by imaging.
foreign body; radio-opaque; splinter; exploration; complication
Foreign body ingestion has been a fundamental subject in the area of emergency surgery. The problem is encountered across all age groups; however, it is more common in the pediatric age group. Foreign body ingestion is rare in adults and usually occurs accidentally or in those with psychiatric problems, behavioral disorders, emotional disturbance, mental retardation, or impaired judgment caused by alcohol use.
Presentation of case
A 33-year-old Caucasian man with chronic schizophrenia was admitted to the emergency department with signs of upper gastrointestinal discomfort as a result of ingestion of a lower dental prosthesis. An abdominal X-ray showed the swallowed dental prosthesis in front of the vertebral column. A technique comprising gastrotomy and duodenal kocherization was used to remove the dental prosthesis; the prosthesis could not be removed endoscopically due to its fixed position on the duodenal wall.
Surgery of the duodenum is difficult and carries high mortality and morbidity. Therefore, endoscopy should be the first choice for patients in whom a foreign object is demonstrated to be fixed in the duodenum. In cases where endoscopic extraction fails, surgery should be considered. During surgery, foreign bodies should be removed, paying meticulous attention not to harm the integrity of the duodenum.
The technique presented in this study was performed successfully without any injury to the duodenum.
Foreign body; Dental prosthesis; Duodenal kocherization; Gastrotomy; Schizophrenia
Three patients involved in illicit drug smuggling via the swallowing of high dose, high purity drugs packed in multiple condoms are reported. Two of these patients experienced drug overdose symptoms due to leakage or rupture of the condoms in the GI tract. They were treated successfully.
Radiologists at a large teaching hospital felt that plain radiograph imaging was being performed inappropriately for patients admitted with acute abdominal pain. They felt requests were either not indicated or CT was a more appropriate first line radiological investigation in certain circumstances.
An audit was performed looking at plain radiograph imaging requests for emergency admissions under general surgery, using Royal College of Radiologists (RCR) guidelines as the standard. The audit revealed that only 80% of plain radiograph requests met RCR guidelines. It also showed that 33% of acute admissions undergoing plain radiograph imaging proceeded to CT within forty-eight hours. These findings lead to the development of a plain radiograph algorithm. This aimed to improve plain radiograph imaging requests and to increase the use of CT as an earlier or first line radiological investigation where appropriate.
Outcome of discussion at local and regional clinical governance meetings was that earlier CT would be useful in specific circumstances. The algorithm provides a framework for appropriately expediting CT in patients presenting with acute abdominal pain where bowel obstruction or perforation was suspected. However, consultant surgeons felt that in patients presenting with acute abdominal pain, the plain abdominal radiograph often demonstrates findings associated with specific diagnoses not specifically indicated by RCR guidelines. If RCR guidelines for plain radiograph imaging are broadened, radiological interpretation would examine for a broader range of findings and, when combined with other clinical information, diagnoses can be made, thus avoiding the need for further imaging or explorative surgery.
Radiograph; abdominal pain; algorithm; Royal College Radiologists guidelines
Swallowing foreign bodies is a common problem in children. Although most objects pass through the gastrointestinal tract with no untoward effect; long, sharppointed, or slender objects can perforate the gut. Migration of a swallowed object to the liver is extremely rare and very few cases have been reported in the literature up to now. The aim of this study is to draw attention to this subject once again by contributing a case report of a child with hepatic migration of a swallowed sewing needle.
A 16-year-old girl presented to the emergency room of pediatrics department in our hospital with complaints of abdominal pain, nausea and vomiting. Physical examination revealed tenderness on the right upper quadrant of the abdomen. Laboratory examination revealed increased hepatic enzymes as well as increased white blood cell count. Abdominal ultrasonography and computed tomography examinations revealed foreign body in the liver accompanied by surrounding abscess formation. The foreign body (sewing needle) was removed surgically after two operations.
The children may not be able to remember the swallowing of the foreign body or they may try to hide such a condition. The radiological diagnosis in such cases which can be achieved by X-rays, ultrasonography or computed tomography is of critical importance, as well as getting detailed patient history for foreign body swallowing.
foreign body swallowing; migration; hepatic; liver
Foreign body ingestion is a common occurrence in childhood. We report the outcome of an infant who swallowed a piece of glass. The absence of a foreign body on chest radiograph led to delayed diagnosis and then to the well documented complications of retropharyngeal abscess and mediastinitis. She was admitted to the paediatric intensive care unit a week after her initial presentation, subjected to multiple invasive and non‐invasive procedures, and 6 weeks after her initial presentation to the accident and emergency department, was discharged back to her referring hospital having re‐established oral feeds.
x ray; foreign body
Introduction. Combined abdominal and thoracic impalement injuries are a rare form of penetrating trauma. Nowadays, they occur more frequently as an accident and not so often as a deliberate violent action. Case Report. A 35-year-old man was admitted to our emergency department with chest pain and respiratory distress after he had reportedly slipped in his bathtub. Abdominal and thoracic imaging, including computed tomography (CT), confirmed a right-sided pneumothorax and a liver laceration without bleeding or further endoperitoneal trauma. A chest tube was placed. During his hospitalization in the first 24-hour period, he complained of abdominal and right shoulder pain accompanied by fever. A new abdominal and thoracic CT scanning revealed a rupture of the rectosigmoid, a rupture of right hemidiaphragm, and a foreign body in the thoracic cavity. The patient admitted that a broomstick was violently placed through his rectum, and he underwent a thoracotomy with an exploratory laparotomy. The foreign object was removed, the diaphragmatic rupture was repaired, and a Hartmann's procedure was performed. The postoperative course was uneventful. Conclusion. In cases of combined thoracoabdominal trauma, high index of suspicion is required when medical history is misleading and the injuries are not obvious immediately. A coordinated team effort in a well-organized trauma center is also very important.
The use of plain radiographs to localize a suspected fishbone foreign body is the subject of controversy. Accordingly radiographs of 14 species of fishbone, impacted in a soft tissue phantom, were assessed by a series of observers from the ENT department (consultant surgeons, senior registrars and house officers). The agreement was assessed by graphical description of the data and tested by a Spearman's rank correlation test. The overall results showed that, for the clinician, radiography is very useful to detect the bones of: cod, haddock, lemon sole, cole fish, grey mullet and plaice; useful for red snapper, monk fish, gurnard and salmon; and unhelpful in detecting bones from herring, pike, mackerel and trout. The use of radiographs to locate these impacted fishbones can be rationalized in the light of these findings.
Soft tissue foreign bodies are a common cause of orthopedic consultation in emergency departments. It is difficult to confirm their existence because conventional radiology only detects radio-opaque foreign bodies. Sonography can be a useful diagnostic method. The aim of this study is to evaluate diagnostic accuracy of sonography in detection and localization of non-opaque foreign bodies.
We evaluated 47 patients with suspected foreign body retention in soft tissues by 10 MHz linear array transducer. A single radiologist performed all examinations with 6 years' experience in musculoskeletal Sonography. We detected and localized the presence of the foreign body in the soft tissue as guidance for facilitating the surgery.
We detected soft tissue foreign body in 45 cases as hyperechoic foci. Posterior acoustic shadowing was seen in 36 cases and halo sign was seen in 5 cases due to abscess or granulation tissue formation. Surgery was performed in 39 patients and 44 foreign bodies were removed.
Sonography is a useful modality in detection and localization of radiolucent foreign bodies in soft tissue which can avoid misdiagnosis during primary emergency evaluation.
Plain abdominal radiographs are commonly requested for acute medical emergencies on patients with non-specific abdominal symptoms and signs. In this study 131 plain abdominal radiographs performed on the day of admission were prospectively analysed. In only 16 cases (12%) the reasons for requests conformed to the recommended guidelines by the Royal College of Radiologists. The reason for the request was stated in the case notes in only three cases. In 62 cases (47%), there was no comment made on the film by the requesting clinician. There was a discrepancy in the interpretation of the radiograph between the clinician and the radiologist in 31 cases (24%). The clinical management was influenced by plain abdominal radiographs in only nine cases (7%). The majority of plain abdominal radiographs requested on acute medical emergencies is inappropriate. There is a need to ensure guidelines are followed to prevent unnecessary exposure of patients to radiation as well as preventing expenditure on irrelevant investigations.
Coin is the most common foreign body swallowed by pediatric age group. The multiple coin swallowing is extremely rare and very few cases had been reported in English literature. Most of them were present at different site and had different alignment in the esophagus. The location of the coin (trachea vs. esophagus) is commonly determined by the alignment of the coin on radiographic studies. A 4-year-girl was presented to us with history of coin ingestions one day back without any respiratory distress. On radiological study there was suspicion of two coins on same location and alignment. The diagnosis was confirmed after removal. The both coin was removed successfully by esophagoscopy. Unexpected second foreign bodies in pediatric esophageal coin ingestions are rare and it is mandatory to do post operative radiography after removal to exclude duplex coin or tracheal coin. We are presenting this case because of its rarity, difficulty in diagnosis especially when proper history is not available.
Extensive body of the literature reveals that proper use of helmets is an effective way to reduce the severity of injuries and fatalities among motorcyclists. However, many motorcyclists do not use safety helmet properly. This study aimed to empirically explore reactions of motorcyclists to the safety helmet laws, in Iran.
Qualitative data were collected via four focus groups and 11 in-depth interviews. Participants were 28 male motorcyclists who never used a safety helmet during rides, and 4 male police officers. All transcripts, codes and categories were read for several times to exhaust identifiable major themes. During this process data were reduced from text to codes and themes.
Five major themes emerged from the data analyses, including themes related to the following: (1) circumventing or dodging police officers; (2) simulating a helmet wearing behavior; (3) accepting the probability of receiving a ticket; (4) taking advantage of the police neglect and carelessness; and (5) using a cheap or convenient helmet.
Our findings suggest certain levels of reckless driving among the participating motorcyclists in this study. They also point to a system of law enforcement that operates haphazardly and fails to consistently penalize those who deviate from it. Further studies are needed to investigate how "risks" are perceived and relate to "reactions", and how a 'culture of masculinity' may encourage risk tolerance and a disposition toward lawlessness and carelessness among male motorcyclists. Also, there is a need for the development and implementation of multidimensional interventions that would offer socio-culturally sensitive educational and motivational messages to the motorcyclists and the in-service traffic-enforcement officers in Iran.
The internal concealment of cocaine and other drugs in packets by “body packers”—those who swallow packets of drugs or hide them in their vagina or rectum—to avoid detection by customs officials has been increasing in both the United States and Europe. The types of package and how they are concealed are changing as the traffickers become more sophisticated in their methods. The latest parcels are less likely to burst, but obstruction of the bowel may occur.
Awareness of the problem is important for staff of emergency medical services near international ports of arrival.
To reduce errors made in the interpretation of radiographs in an emergency department.
Hospital emergency department.
All staff reviewed all clinically significant discrepancies at monthly meetings. A file of clinically significant errors was created; the file was used for teaching. Later a team redesigned the process. A system was developed for interpreting radiographs that would be followed regardless of the day of the week or time of day. All standard radiographs were brought directly to the emergency physician for immediate interpretation. Radiologists reviewed the films within 12 hours as a quality control measure, and if a significant misinterpretation was found patients were asked to return.
Main outcome measures
Reduction in number of clinically significant errors (such as missed fractures or foreign bodies) on radiographs read in the emergency department. Data on the error rate for radiologists and the effect of the recall procedure were not available so reliability modelling was used to assess the effect of these on overall safety.
After the initial improvements the rate of false negative errors fell from 3% (95% confidence interval 2.8% to 3.2%) to 1.2% (1.03% to 1.37%). After the processes were redesigned it fell further to 0.3% (0.26% to 0.34%). Reliability modelling showed that the number of potential adverse effects per 1000 cases fell from 19 before the improvements to 3 afterwards and unmitigated adverse effects fell from 2.2/1000 before to 0.16/1000 afterwards, assuming 95% success in calling patients back.
Systems of radiograph interpretation that optimise the skills of all clinicians involved and contain reliable processes for mitigating errors can reduce error rates substantially.