Management of Patients With Drug Packet Ingestion (Body Packers): A Narrative Review

,

Hormozgan Med J. Vol 26, No 3, 2022 164 hmj.hums.ac.ir http be noted that these individuals do not normally provide the doctor with specific information.

Clinical Examinations
The condition of a packet containing any opening or leakage can be determined by several factors, including consciousness, emotional state, vital signs, pupil size, and bowel sounds. An abdominal examination can identify distension or the presence of packets (12). Vaginal and rectal examinations can occasionally aid in the discovery of packets. Other examinations do not provide further information to the examiner (13,14).

Radiological Examinations
The diagnosis of individuals with a complete history of swallowing packets or those who exhibit poisoning symptoms is not difficult; nonetheless, radiography can be beneficial for the majority of those who do not have any symptoms. Abdominal X-rays can identify foreign bodies in the digestive system. According to some studies (6,15,16), the sensitivity of plain abdominal radiography is 85%-90% based on a specific radiographic view (the "double condom" sign) and can be used as a screening test ( Figure 1). Multiple foreign bodies in supine abdominal radiography further implied that heroin packets may have been swallowed (6,(17)(18)(19). The effectiveness of ultrasonography and other screening procedures has been found to be insufficient in various investigations, but the sensitivity and specificity have not been well studied yet (14,(20)(21)(22).
Due to the radiolucency of liquid cocaine in plain X-rays and when there is a strong suspicion that a drug packet has been consumed, abdominal and pelvic computed tomography (CT) scanning should be performed, first without contrast and then with contrast if necessary (14,(23)(24)(25)(26). The packets are found in these CT scans as multiple foreign objects surrounded by a small volume of gas ( Figure 2). Undoubtedly, CT specificity is greater than that of conventional radiography, and the type of material included in the packet has been identified even in research utilizing the Hounsfield scale (27,28). Contrast-enhanced abdominal radiography, which has a sensitivity of 96%, is one of the most sensitive diagnostic techniques (12).

Management
Numerous books and articles have been published about the management and treatment of such patients which are briefly presented as follows:

Opioid Poisoning
When a person exhibits signs of drug intoxication from opium or heroin, opioid antagonists (naloxone hydrochloride) are administered in repeated doses of 2-5 mg. It is continued as the following continuous infusion to ensure a satisfactory clinical result (29)(30)(31).

Cocaine Poisoning and Other Stimulant Drugs Such as Amphetamines
Surgery is strongly advised to remove packets in symptomatic individuals because there is no antagonist for the effective treatment of these drugs. Conservative therapy is recommended for the management of additional symptoms. For seizure management, benzodiazepines are employed, while lidocaine and sodium bicarbonate are used to avoid cardiac dysrhythmias. To lower blood pressure, sodium nitroprusside should be used rather than beta-blockers (12).

Ileus, Obstruction, or Peritonitis Due to Perforation
Body packers frequently have intestinal obstruction;  hmj.hums.ac.ir http however, intestinal perforation and esophageal obstruction are far less common (19). The foregoing issues are unrelated to the quantity of packets (19,32).

Asymptomatic Patients
Without any symptoms, patients do not require emergency surgery or other supportive treatments such as enema. According to several in-depth studies in this field, the surgical procedure to remove the packets is only advised if the patient is really concerned about packet perforation or when packaging is highly novice (24). Conservative treatment is recommended for packets that have been retained in the stomach for longer than 48 hours. However, there is disagreement regarding the precise timing of surgery; In general, 5-7 days are suggested for packet passage (11). Whole bowel irrigation with poly ethylene glycol is the best option for the rapid removal of pockets.

Detoxification
Numerous studies have suggested that patients take detox medications as they get ready for surgery. These medications include polyethylene glycol solution (2 L/h) or activated charcoal (1 g/kg of the patient's weight every four hours. This decontamination continues until the gastrointestinal tract is cleaned entirely. Some researchers have recommended using gastrointestinal stimulants together with metoclopramide and erythromycin (29,33).

Endoscopy
The risk of packet rupture still prevents the routine use of this technique despite reports on effective packet removal by endoscopy (29). Therefore, it is advised that packet removal be performed selectively. When a packet ruptures, a surgical team and antagonists should be available. Additionally, it is preferable to remove the packets using appropriate recyclable bags (30).

Surgery
In our experience, a young man had a seizure after ingesting a 10-gram packet of methamphetamine while receiving emergency care. A drug-containing plastic packet leak was discovered during the autopsy. In other instances, patients succumbed to multiorgan failure, brain injury, and loss of consciousness in the intensive care unit. Laparotomies were performed on four patients who lacked pertinent information; two of them had heroin packets discovered in their stomachs, while in the other two, packets were found in their intestines (Figure 3). There was also a case of distal ileum obstruction brought on by an ingested opium packet that was removed by proximal enterotomy. Finally, in our opinion, surgical intervention is unquestionably necessary for acute cocaine and amphetamine intoxication, gastrointestinal obstruction, and peritonitis due to intestinal perforation. To remove the packets surgically, an enterotomy is performed proximal to the packets, preferably in the clean regions of the intestine. The packets are then removed by milking. In the unclean portions of the gut (colon), the packets can be milked out to the anus (29,32). If a perforation has already developed, a colostomy will be used. The removal of all packets following surgery is confirmed using one of the radiological modalities, namely, CT scan or contrasted X-ray (30). Complications, including wound infection and dehiscence with damage to the fascia, have been observed in all cases following packet removal through colostomy (10). Moreover, in patients who have had conservative therapy, the complete removal of the packets should be validated by counting the packets or cutting-edge radiological techniques. The use of a CT scan or contrasted X-ray is recommended, and all packages should be delivered to hospital security (10,34).

Recommended Solutions
After performing a thorough physical examination, obtaining the patient's history, and performing primary resuscitation, a toxicologist should be consulted regarding the aforementioned issues when dealing with such individuals. A plain abdominal flat and upright X-ray can be utilized to confirm the diagnosis. Abdominal CT, with or without oral contrast, can be performed in cases when certain packets are not recognized, especially where liquid cocaine is suspected. First, it is preferable to perform a CT with contrast if there is enough time (12). If the items are small and in the stomach of asymptomatic patients, a skilled individual can remove them with an endoscope and a recycle bag (35). Due to the possibility of leakage, it is preferable to surgically remove stimulant substances such as cocaine. Whole bowel irrigation is performed using polyethylene glycol when packets are in the bowels (36,37). All expulsed packets should be gathered and counted to match the number of packets that were ingested. The expulsion of all packets is verified if the patient has at least two bowel movements without the presence of drug packets, or by appropriate imaging. If a package remains after five days, it is best to surgically remove it (11). Figure 4 presents the management algorithm of drug hmj.hums.ac.ir http packers. After initial resuscitation and treatment of poisoning symptoms in symptomatic patients, laparotomy should be performed for the removal of packets if there is any obstruction or peritonitis caused by a perforation of the intestine. Naloxone and other medications are used in the treatment of individuals who show signs of opium and heroin intoxication. Although many cases may be treated conservatively, we recommend surgery to remove the remaining packets in the absence of an appropriate response ( Figure 4).
Due to the low lethal dose and lack of perfect antidote in the symptomatic carriers of cocaine or other stimulants, we advise that after initial resuscitation and proportional control of provocation-related symptoms, the patient be transferred to the operating room as soon as possible for surgical removal of the packets (Figure 4). Researchers are currently prioritizing the need for more accurate detection and effective treatment of these patients due to the development of air transportation, the production of new drugs, and improvements in package production technology; as a result, sharing new information between authors and researchers is highly beneficial.

Conclusion
Despite the involved health hazards, it appears that the intra-corporeal carriage of illegal drugs for international trafficking is growing. Imaging is becoming more prevalent to reduce morbidity and mortality, as well as to discourage the practice of body packing or pushing. This technique is used to detect packets and look into potential clinical consequences once a patient has been brought to the attention of a doctor. Although conservative treatment is often employed for these individuals, early surgical intervention for packet removal is advised in the cases of ingesting cocaine and amphetamine packets because of the lack of an appropriate antagonist.
Due to the development of air transport and production of new drugs and advances in packages production technology, more accurate detection and effective treatment of these patients are the priority of researchers, thus the exchange of new information between authors and researchers is extremely useful.