Body packing may expose the patient to a significant number of complications, including acute poisoning after rupture of the packages, or more exceptionally, intestinal obstruction. Most of the patients can be managed conservatively by oral laxatives. However, surgical intervention has been recommended in cases of package retention beyond 5-7 days to prevent package leakage, rupture and obstruction. We report a recent case of oesophageal and gastric obstruction caused by a large number of cocaine-containing packages.

A 49-year-old previously healthy woman originated from East Africa was found stuporous at the railway station of the airport. Her consciousness rapidly deteriorated before the arrival of the first medical rescuers. She was then found with a Glasgow Coma Score of 3/15, bradypnea 4/min, heart rate 60/min, arterial blood pressure 140/90mm Hg and oxygen saturation (SpO2) 91%. Pinpoint pupils were also remarkable. Orotracheal intubation was performed. The diagnosis of opioid poisoning was supported by the clinical response to a single i.v. dose of 0,4mg naloxone. Soon after the admission in the Emergency Department, an abdomen computed tomography (CT) was obtained due to the high suspicion of body packing. It confirmed the presence of multiple packs: 81 in the dilated stomach, 1 in the lower part of the oesophagus and 8 in the sigmoid and rectum. Toxicological analysis revealed: serum morphine 0,73μg/ml, codeine 0,06μg/ml; urine benzoylecgonine 0,015μg/ml, 6-MAM 0,351μg/ml, codeine 17,6μg/ml. As the patient did not present any clinical sign of acute cocaine toxicity, a conservative approach was proposed by whole bowel irrigation (polyethylene glycol). The patient only complained from abdominal discomfort. Extubation was not possible due to persisting opiod syndrome. (The patient admitted later on having ingested morphine and codeine to decrease intestinal peristaltism). On hospital day 4, the patient became mildly tachycardic and hypertensive, and abdominal discomfort worsened. There was no significant increase in urine benzoylecgonone concentration. A new abdomen CT showed no significant progression of the packages; 9 had been removed after laxative therapy. The stomach appeared extremely dilated. A surgical procedure was decided (gastrotomy). On the whole, one pack was removed from the lower oesophagus, 79 from the stomach, and three additional packages were evacuated after palpation of the colon. The post-operative course was not complicated and extubation was possible 48 hours later. The abdomen CT confirmed the complete evacuation.

The exact incidence of intestinal obstruction following body packing is not known, but is probably reaching 5%. The main risk is the rupture of the packages with acute cocaine intoxication. Emergency laparotomy is the only therapeutic option when the patient is becoming symptomatic. In the present observation, conservative therapy failed due the presence of a large amount of packages that had accumulated in the stomach. This high number of packages did not allow removal by endoscopy. The literature data show that surgery is mainly indicated when the packages are located in the stomach or in the small bowel.