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A 57-year-old man self-referred to the emergency department. Upon arrival he had a grand mal seizure followed by a cardiac arrest. Cardiac output was promptly restored. As seizures continued infusions of propofol, midazolam and phenytoin were started. Empirical aciclovir and ceftriaxone were also given. A head CT and lumbar puncture were non-diagnostic. An amylase of 795 IU/l precipitated an abdominal CT scan (figs 1A and B).
The contrast-enhanced CT scan through the abdomen and pelvis showed multiple rounded opacities of slightly heterogeneous attenuation, each surrounded by a thin ring of low attenuation. They measured 1.8 cm in diameter. The density of the rings was similar to that of air. These opacities were seen in the stomach (fig 1A) with further opacities seen within the sigmoid colon and rectum (fig 1B). One of the opacities lying on its long axis in the sigmoid colon appears sausage-shaped, and more clearly shows that external to the rim of air is a further enveloping rim of higher attenuation. These opacities are clearly not normal bowel residue, containing a central sausage-shaped density surrounded by a thin layer of trapped air and an outer membrane. These were found at laparotomy to be condoms packed with cocaine.
This case exemplifies body packing or internal concealment of illicit substances in an attempt to elude customs. In uncomplicated cases conservative management with laxatives or bowel irrigation may be preferred. Rupture of the packet warrants surgical intervention. In this case at laparotomy, 32 packages (average weight 10 g) were removed (fig 2). One of them showed evidence of rupture. The contents were cocaine. Plain films identify up to 89% of drug packets ingested and CT may be a better investigation.
Most body packers have no complications. Complications, including packet rupture or intestinal obstruction, occur in 1.3–2.2% of cases.1 2Cocaine toxicity is lethal if not treated, but otherwise the prognosis is good. Prompt surgery is life saving. In a large series of 2880 body packers, rupture of the packet occurred in 63 patients. Of those, 20 underwent a laparotomy and survived; the others died.2
This article has been adapted from Szawarski P, Dvorkin L, Tam E. Laparotomy for treatment of seizures Emergency Medicine Journal 2008;25:120
Competing interests: None.