Successful endoscopic removal of a cocaine capsule in the stomach: should it be considered a safe therapeutic option?

Body packers, also called “swallowers” or “mules”, are people who swallow amounts of wrapped drugs [1] [2]. In those who are asymptomatic, conservative treatment should be considered, so allowing spontaneous passage of the packets [1] [3]. When this fails, surgery is usually the first option [4] [5] [6]. However, as suggested by a review article on internal concealment of illicit drugs [3], endoscopic removal can be a therapeutic option and is a reasonable alternative to surgery when only one packet has failed to pass beyond the pylorus. There are only three cases reported in the literature of the successful endoscopic extraction of cocaine packets from the upper digestive tract [7] [8] [9].

A 41-year-old man was referred to the emergency department because of voluntary ingestion of 100 packets containing cocaine. An abdominal radiograph revealed multiple radiodense foreign bodies in the ascending colon with the “double-condom” sign ([Fig. 1]), a sign produced by the rim of air trapped between two condoms [2].

Fig. 1 Abdominal radiograph showing multiple radiodense foreign bodies with the “double-condom” sign (arrows).

Colonic preparation with polyethylene glycol – electrolyte solution was started and the patient was kept under observation for 48 hours in the emergency department. The evacuation of 99 capsules was observed. After 72 hours, an abdominopelvic computed tomography (CT) scan was performed, which revealed a single capsule that had been retained in the gastric cavity ([Fig. 2]). Careful direct inspection of the other evacuated capsules showed that they had a double coating of latex.

Fig. 2 Abdominal computed tomography (CT) images showing the remaining capsule in the gastric cavity: a in axial view; b in coronal view.

Upper gastrointestinal endoscopy was performed and revealed a single capsule, 60 × 15 mm in size, with cylindrical appearance. Endoscopic extraction was first attempted with a net retriever (net size of approximately 3 cm; Roth Net, US Endoscopy) but this was unsuccessful. The procedure was then executed with a 10-mm snare (Olympus), the capsule being held by a knot located at one end of the packet, which allowed the capsule to be successfully removed without complications ([Fig. 3] and [Fig. 4]).

Fig. 3 View during upper gastrointestinal endoscopy showing the gastric cavity containing a cylindrical capsule at the greater curvature, which was successfully removed with a snare.

Fig. 4 Photograph of the cylindrical cocaine package removed from the patient, which measured 60 × 15 mm.

The endoscopic removal of packets of drugs remains controversial as a risk of packet perforation exists; however, it can be considered as a reasonable alternative to surgery [3].

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• References

• 1 Claffey M. Stampede of drug mules at Kennedy: after 9/11 lull, heroin & ecstasy busts soar. New York Daily News; 05.05.2002
• 2 June R, Aks SE, Keys N et al. Medical outcome of cocaine bodystuffers. J Emerg Med 2000; 18: 221-224
• 3 Traub S, Hoffman R, Nelson L. Body packing – the internal concealment of illicit drugs. N Engl J Med 2003; 349: 2519-2526
• 4 Robinson T, Birrer R, Mandava N et al. Body smuggling of illicit drugs: two cases requiring surgical intervention. Surgery 1993; 113: 709-711
• 5 de Beer SA, Spiessens G, Mol W et al. Surgery for body packing in the Caribbean: a retrospective study of 70 patients. World J Surg 2008; 32: 281-285
• 6 Beck NE, Hale JE. Cocaine ‘body packers’. Br J Surg 1993; 80: 1513-1516
• 7 Sherman A, Zingler BM. Successful endoscopic retrieval of a cocaine packet from the stomach. Gastrointest Endosc 1990; 36: 152-154
• 8 Choudhary AM, Taubin H, Gupta T et al. Endoscopic removal of a cocaine packet from the stomach. J Clin Gastroenterol 1998; 27: 155-156
• 9 Macedo G, Ribeiro T. Esophageal obstruction and endoscopic removal of a cocaine packet. Am J Gastroenterol 2001; 96: 1656-1657