Clinical Radiology (1992) 45, 322 325
Abdominal Radiography in Suspected 'Body Packers' A. W. H O R R O C K S
Department o,1 Radiology, Wythenshawe Hospital, Manchester Drug smuggling by intra-abdominal concealment is now a world-wide problem. This paper describes the establishment of a plain radiography service to assist customs officers of Manchester International Airport (MIA) in their work. Over a 2½ year period, 158 suspected 'body packers' were radiographed, resulting in nine positive detections. The existence of the service has resulted in the apparent abandonment of MIA as a port of entry by an organized group of cocaine smugglers. Practical and ethical problems are described. This service is felt to be essential by the customs officers and a valuable service to society by the radiologists and hospital authorities concerned. Horrocks, A.W. (1992). Clinical Radiology 45, 322 325. Abdominal Radiography in Suspected 'Body Packers'
The carriage of controlled drugs across international borders, by means of concealment within body cavities, is well established as a method employed in the attempt to avoid detection by H.M. Customs and Excise Authorities (HMCE). Reports of detection by radiographic examination have appeared sporadically since 1974, predominantly from the USA and Australia (Lopez et al., 1974; Dasset and Punjabi, 1979; Vowels and Harvey, 1980; Dunne, 1983). Oral ingestion of packages containing drugs, or concealment by insertion into the rectum or vagina, carries considerable risk. Leakage of the drug either through or from its chosen method of containment may lead to overdose of the carrier which is frequently fatal (Beltinger, 1980; Wetli and Mittleman, 1981). An additional concern for the 'body packer' is the possibility of contamination of the concealed substance, rendering it valueless. These risks increase in proportion to the length of concealment within the body, wrappings having been observed to deteriorate on serial radiographs (Lancashire et al., 1988). This method of smuggling is consequently largely confined to those travelling by air, although similar methods have been used to smuggle illicit substances into prisons (Pagliuca and Mufti, 1991). Intestinal obstruction is a further hazard which may require surgical intervention (Freed et al., 1976; Dunne, 1983; Lancashire et al., 1988). Wythenshawe Hospital is a large District General Hospital situated 4 miles from Manchester International Airport (MIA). MIA is the third busiest airport in the U K with direct or connecting flights to virtually any worldwide destination. In 1988 the hospital management was approached by HMCE, with a request to provide facilities by which suspected 'body packers' could be radiographed. This paper describes the methods adopted and the results obtained. METHODS A protocol was designed and agreed with the Surveyor Preventive H M C E based at MIA before the commencement of the service in 1988. The protocol was designed to prevent requests being made for examinations on suspects who would not consent, were unable to consent or might be pregnant. All suspects examined were volunteers, Correspondenceto: Dr A. W. Horrocks, Department of Radiology, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT.
choosing to be radiographed rather than undergo an extended period of detention by H M C E on suspicion of concealing illicit substances. It was also established that requests would not be made outside normal working hours except in exceptional circumstances, e.g. imminent expiry of a period of custody. Requests for suspects to be radiographed were made by or on behalf of the Surveyor Preventive HMCE. No examination was carried out without the written consent of the suspect. Persons under the age of 18 were thus excluded, parental consent being unacceptable. Consent was obtained initially by the H M C E officer in charge of the case and then confirmed by a radiologist on arrival in the hospital, the signed consent form being retained by the radiologist concerned. This method was adopted to ensure that consent was indeed voluntary and informed. Female patients had an addition to their consent forms so that the last menstrual period could be recorded and fetal protection guidelines (NRPB, 1988) observed. Difficulties arose with suspects who did not speak English; in these circumstances the radiologist had to be satisfied that the patient had given informed and voluntary consent by means of an interpreter. The standard examination for suspects consisted of a single supine abdominal film. In tall men it was not infrequently necessary to divide the abdomen and carry out two exposures to image the whole abdomen, in order to include the fundus of the stomach which lies under the diaphragm in the supine position as well as the rectum. This film was then viewed by the radiologist and the necessity for any further projections determined. Either a lateral projection of the pelvis or a pelvic ultrasound (US) examination was obtained in women if the abdominal film was at all suspicious. Experience has demonstrated that objects inserted into the vagina are difficult to detect on the supine abdominal film alone as they are seen 'end on', projected over the sacrum and coccyx. The lateral pelvic film was largely replaced by pelvic US examination during the study period in order to minimize radiation dosage. Since the adoption of this routine, the radiologists felt more confident in excluding packages in the female pelvis (Fig. 1). RESULTS
Between May 1988 and December 1990, 158 suspected 'body packers' were radiographed (110 male, 48 female).
ABDOMINAL RADIOGRAPHY IN SUSPECTED ~BODY PACKERS'
323
(a)
Fig. 2 - The stomach and upper small bowel packed with condoms filled with cannabis oil.
(b) Fig. 1 (a) Supine and abdominal film reveals suspicious opacities in the pelvis. (b) Suspicious opacities demonstrated to have a linear lucent 'halo' and lie in the upper vagina in the lateral projection.
Their journeys had commenced in m a n y countries, predominantly The Netherlands, Nigeria, Morocco, Ghana, Pakistan, Thailand, and the USA. Nine examinations were reported as positive and subsequently proven to be so by recovery of illicit substances from stools, or by removal from the vagina. A count of the ingested or concealed packets was possible in seven cases, the other two being impossible to estimate due to a very large number of overlapping images of condoms containing cannabis oil (Fig. 2). Two cases were reported as 'suspicious, but not definite' due to the presence of large, dense faecal masses. Neither of these cases subsequently proved positive on stool examination. One hundred and forty-seven were reported as negative. In the few cases where suspects were detained after radiographic examination (e.g. for immigration or passport irregularities) no false negatives were reported. Three incidental findings were recorded. These were a renal calculus, a pelvic
Fig. 3 Tape-wrapped heroin packets in the colon. Analysis on retrieval yielded 153 g of impure heroin with an estimated street value of £ 15 000.
dermoid cyst which contained a tooth and a collection of calcified guinea worms. The illicit substances encountered during the period described were heroin, cocaine, cannabis resin, cannabis oil and methyl dioxy methyl amphetamine ( M D M A -
324
CLINICAL RADIOLOGY
Fig. 6 - Cannabis resin pellets in the vagina, air 'halo' of wrappings identifiable.
Fig. 4 - Similar case to Fig. 3, the colon being packed with a large number of small tape-wrapped packets.
Fig. 5 - Cannabis resin wrapped in cling film in the rectum. Density of packages more apparent than their faint lucent 'halo'.
'Ecstasy'). On one occasion the presence of an intravaginal package was confirmed by US examination. In positive cases, counting the number of concealed packages enabled H M C E to recover all the ingested contraband without unnecessary searching of faeces, a task universally disliked by the officers concerned. DISCUSSION The majority of suspects are users of illicit substances and are 'body packing' to bring into the U K supplies for
their own use, from countries where the drugs are both easily available and inexpensive. They have frequently been using drugs intensively while outside the U K before attempting to return with concealed packages. A well recognized effect of these substances is to produce constipation. Dense faecal masses in the colon and particularly the rectum may produce suspicious images and are largely responsible for the occasional need to obtain lateral projections of the rectum in men. Detection of concealed packages is made possible by identification of dense wrapping material (with or without locculi of air), regularity of shape and occasionally by the high density of closely packed material (Figs 3 6). A classification of cocaine-containing packages has been described (McCarron and Wood, 1983) but has proved of little practical value due to advances in technology and the ingenuity of 'body packers'. The decision to provide a service to H M C E for radiographic examination of suspects can only be made with the agreement of both hospital management and the radiologists concerned. Legal and ethical concerns which might influence the radiologists' decision have been addressed by a President of the Royal College of Radiologists (Craig, 1990). With the benefit of legal opinion provided by the Medical Defence and Protection Societies it was established that under the authority of a senior Police or H M C E officer, a request could be made that a suspect be radiographed in safe circumstances, to the mutual benefit of the suspect and the detaining authority in expeditiously resolving a situation of 'reasonable suspicion'. It was also stated that no radiographer or radiologist involved could be compelled to undertake such an examination, particularly if he/she was in any way dissatisfied with either the grounds for suspicion or the quality of consent obtainable. This guidance regarding the need to examine and obtain informed consent, in addition to scrupulous radiographic technique (the 'As low as reasonably achievable' or 'ALARA' principle (IRCP, 1991)) and fetal protection, are of paramount importance. Radiographers and radiologists are not part of the judicial process and should therefore adopt a neutral position, preventing coercion by law enforcement bodies whilst at the same time remembering a duty both to public interest and to the suspect in protecting against unnecessary examination. The latter duty also includes the necessity to detect potentially dangerous packages in the
ABDOMINAL RADIOGRAPHYIN SUSPECTED 'BODY PACKERS' knowledge o f previous fatalities (Beltinger, 1980; Wetli and M i t t l e m a n , 1981). The effectiveness o f such a service is difficult to assess. We have h a d n o k n o w n false negatives b u t this c a n n o t be proven in a n y way. Freislederer et al. (1988) d e m o n strated experimentally that c o m p u t e d t o m o g r a p h y offers the highest rate of detection o f ingested packages b u t this m e t h o d is impracticable in the r o u t i n e m a n a g e m e n t of suspects. P r o b a b l y the most valuable c o n t r i b u t i o n a radiography service offers is that of a deterrent to organized, routine smuggling o f controlled substances. A series of successful detentions, detections and s u b s e q u e n t prosecutions of such a group, smuggling cocaine f r o m the c o n t i n e n t o f Africa, has resulted in the a p p a r e n t a b a n d o n m e n t o f M I A as a port of entry. It r e m a i n s the o p i n i o n of the radiologists c o n c e r n e d that this service is a valuable c o n t r i b u t i o n to society as a whole. Acknowledgements. l wish to thank Mrs Judy White for her help in research for this paper and Mrs Gwen Oliver for preparing this manuscript. REFERENCES
Beltinger,J (1980). Cocaine intoxication: massive oral overdose. Annals of Emergency Medicine, 9, 429 430. Craig, JOMC (1990). Editorial. Radiography of suspected drug smugglers. Clinical Radiology, 41,228.
325
Dassel, PM & Punjabi, E (1979). Ingested marihuana filled balloons. Gastroenterology, 76, 166 169. Dunne, JW (1983). Drug smuggling by internal bodily concealment. Medical Journal of Australia, 2, 436-439. Freed, TA, Sweet, LN & Gauder, PJ (1976). Balloon obturation bowel obstruction: a hazard of drug smuggling. American Journal of Roentgenology, 127, 1033-1034. Freislederer, A, Bautz, W & Schmidt, V (1988). Body-Packing: Wertigkeit moderner bildgebender Verfahren zum Nachweis inkorporierter Transportmedien. Archivefiir Kriminologie, 182, 145-153. ICRP (1991). 1990 Recommendations of the International Commission on Radiological Protection. ICRP Publication 60, Pergamon Press, Oxford. Lancashire, MJR, Legg, PK, Lowe, M, Davidson, SM & Ellis, BW (1988). Surgical aspects of international drug smuggling. British Medieal Journal, 296, 1035 1037. Lopez, HH Jr, Goldman, SM, Liberman, II & Barnes, DT (1974). Cannabis accidental peroral intoxication: the hashish smuggler roentgenographically unmasked. Journal of the American Medical Association, 227, 1041 1042. McCarron, MM & Wood, JD (1983). The cocaine 'body packer' syndrome-diagnosis and treatment. Journal of the American Medical Association, 250, 1417 1420. National Radiation Protection Board (NRPB) (1988). Guidance notes for the protection of persons against ionising radiations arising from medical and dental use. HMSO. Pagliuca, A & Mufti, GJ (1991). Warnings over cling film. British Medical Journal, 302, 593. Vowels, M & Harvey, P (1980). Ingestion of hashish oil filledcondoms. Medical Journal of Australia, 2, 509-510. Wetli, CV & Mittleman, RE (1981). The 'body packet syndrome' toxicity following ingestion of illicit drugs packed for transportation. Journal of Forensic Science, 26, 492 500.
Abdominal Radiography in Suspected 'Body Packers' A. W. H O R R O C K S
Department o,1 Radiology, Wythenshawe Hospital, Manchester Drug smuggling by intra-abdominal concealment is now a world-wide problem. This paper describes the establishment of a plain radiography service to assist customs officers of Manchester International Airport (MIA) in their work. Over a 2½ year period, 158 suspected 'body packers' were radiographed, resulting in nine positive detections. The existence of the service has resulted in the apparent abandonment of MIA as a port of entry by an organized group of cocaine smugglers. Practical and ethical problems are described. This service is felt to be essential by the customs officers and a valuable service to society by the radiologists and hospital authorities concerned. Horrocks, A.W. (1992). Clinical Radiology 45, 322 325. Abdominal Radiography in Suspected 'Body Packers'
The carriage of controlled drugs across international borders, by means of concealment within body cavities, is well established as a method employed in the attempt to avoid detection by H.M. Customs and Excise Authorities (HMCE). Reports of detection by radiographic examination have appeared sporadically since 1974, predominantly from the USA and Australia (Lopez et al., 1974; Dasset and Punjabi, 1979; Vowels and Harvey, 1980; Dunne, 1983). Oral ingestion of packages containing drugs, or concealment by insertion into the rectum or vagina, carries considerable risk. Leakage of the drug either through or from its chosen method of containment may lead to overdose of the carrier which is frequently fatal (Beltinger, 1980; Wetli and Mittleman, 1981). An additional concern for the 'body packer' is the possibility of contamination of the concealed substance, rendering it valueless. These risks increase in proportion to the length of concealment within the body, wrappings having been observed to deteriorate on serial radiographs (Lancashire et al., 1988). This method of smuggling is consequently largely confined to those travelling by air, although similar methods have been used to smuggle illicit substances into prisons (Pagliuca and Mufti, 1991). Intestinal obstruction is a further hazard which may require surgical intervention (Freed et al., 1976; Dunne, 1983; Lancashire et al., 1988). Wythenshawe Hospital is a large District General Hospital situated 4 miles from Manchester International Airport (MIA). MIA is the third busiest airport in the U K with direct or connecting flights to virtually any worldwide destination. In 1988 the hospital management was approached by HMCE, with a request to provide facilities by which suspected 'body packers' could be radiographed. This paper describes the methods adopted and the results obtained. METHODS A protocol was designed and agreed with the Surveyor Preventive H M C E based at MIA before the commencement of the service in 1988. The protocol was designed to prevent requests being made for examinations on suspects who would not consent, were unable to consent or might be pregnant. All suspects examined were volunteers, Correspondenceto: Dr A. W. Horrocks, Department of Radiology, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT.
choosing to be radiographed rather than undergo an extended period of detention by H M C E on suspicion of concealing illicit substances. It was also established that requests would not be made outside normal working hours except in exceptional circumstances, e.g. imminent expiry of a period of custody. Requests for suspects to be radiographed were made by or on behalf of the Surveyor Preventive HMCE. No examination was carried out without the written consent of the suspect. Persons under the age of 18 were thus excluded, parental consent being unacceptable. Consent was obtained initially by the H M C E officer in charge of the case and then confirmed by a radiologist on arrival in the hospital, the signed consent form being retained by the radiologist concerned. This method was adopted to ensure that consent was indeed voluntary and informed. Female patients had an addition to their consent forms so that the last menstrual period could be recorded and fetal protection guidelines (NRPB, 1988) observed. Difficulties arose with suspects who did not speak English; in these circumstances the radiologist had to be satisfied that the patient had given informed and voluntary consent by means of an interpreter. The standard examination for suspects consisted of a single supine abdominal film. In tall men it was not infrequently necessary to divide the abdomen and carry out two exposures to image the whole abdomen, in order to include the fundus of the stomach which lies under the diaphragm in the supine position as well as the rectum. This film was then viewed by the radiologist and the necessity for any further projections determined. Either a lateral projection of the pelvis or a pelvic ultrasound (US) examination was obtained in women if the abdominal film was at all suspicious. Experience has demonstrated that objects inserted into the vagina are difficult to detect on the supine abdominal film alone as they are seen 'end on', projected over the sacrum and coccyx. The lateral pelvic film was largely replaced by pelvic US examination during the study period in order to minimize radiation dosage. Since the adoption of this routine, the radiologists felt more confident in excluding packages in the female pelvis (Fig. 1). RESULTS
Between May 1988 and December 1990, 158 suspected 'body packers' were radiographed (110 male, 48 female).
ABDOMINAL RADIOGRAPHY IN SUSPECTED ~BODY PACKERS'
323
(a)
Fig. 2 - The stomach and upper small bowel packed with condoms filled with cannabis oil.
(b) Fig. 1 (a) Supine and abdominal film reveals suspicious opacities in the pelvis. (b) Suspicious opacities demonstrated to have a linear lucent 'halo' and lie in the upper vagina in the lateral projection.
Their journeys had commenced in m a n y countries, predominantly The Netherlands, Nigeria, Morocco, Ghana, Pakistan, Thailand, and the USA. Nine examinations were reported as positive and subsequently proven to be so by recovery of illicit substances from stools, or by removal from the vagina. A count of the ingested or concealed packets was possible in seven cases, the other two being impossible to estimate due to a very large number of overlapping images of condoms containing cannabis oil (Fig. 2). Two cases were reported as 'suspicious, but not definite' due to the presence of large, dense faecal masses. Neither of these cases subsequently proved positive on stool examination. One hundred and forty-seven were reported as negative. In the few cases where suspects were detained after radiographic examination (e.g. for immigration or passport irregularities) no false negatives were reported. Three incidental findings were recorded. These were a renal calculus, a pelvic
Fig. 3 Tape-wrapped heroin packets in the colon. Analysis on retrieval yielded 153 g of impure heroin with an estimated street value of £ 15 000.
dermoid cyst which contained a tooth and a collection of calcified guinea worms. The illicit substances encountered during the period described were heroin, cocaine, cannabis resin, cannabis oil and methyl dioxy methyl amphetamine ( M D M A -
324
CLINICAL RADIOLOGY
Fig. 6 - Cannabis resin pellets in the vagina, air 'halo' of wrappings identifiable.
Fig. 4 - Similar case to Fig. 3, the colon being packed with a large number of small tape-wrapped packets.
Fig. 5 - Cannabis resin wrapped in cling film in the rectum. Density of packages more apparent than their faint lucent 'halo'.
'Ecstasy'). On one occasion the presence of an intravaginal package was confirmed by US examination. In positive cases, counting the number of concealed packages enabled H M C E to recover all the ingested contraband without unnecessary searching of faeces, a task universally disliked by the officers concerned. DISCUSSION The majority of suspects are users of illicit substances and are 'body packing' to bring into the U K supplies for
their own use, from countries where the drugs are both easily available and inexpensive. They have frequently been using drugs intensively while outside the U K before attempting to return with concealed packages. A well recognized effect of these substances is to produce constipation. Dense faecal masses in the colon and particularly the rectum may produce suspicious images and are largely responsible for the occasional need to obtain lateral projections of the rectum in men. Detection of concealed packages is made possible by identification of dense wrapping material (with or without locculi of air), regularity of shape and occasionally by the high density of closely packed material (Figs 3 6). A classification of cocaine-containing packages has been described (McCarron and Wood, 1983) but has proved of little practical value due to advances in technology and the ingenuity of 'body packers'. The decision to provide a service to H M C E for radiographic examination of suspects can only be made with the agreement of both hospital management and the radiologists concerned. Legal and ethical concerns which might influence the radiologists' decision have been addressed by a President of the Royal College of Radiologists (Craig, 1990). With the benefit of legal opinion provided by the Medical Defence and Protection Societies it was established that under the authority of a senior Police or H M C E officer, a request could be made that a suspect be radiographed in safe circumstances, to the mutual benefit of the suspect and the detaining authority in expeditiously resolving a situation of 'reasonable suspicion'. It was also stated that no radiographer or radiologist involved could be compelled to undertake such an examination, particularly if he/she was in any way dissatisfied with either the grounds for suspicion or the quality of consent obtainable. This guidance regarding the need to examine and obtain informed consent, in addition to scrupulous radiographic technique (the 'As low as reasonably achievable' or 'ALARA' principle (IRCP, 1991)) and fetal protection, are of paramount importance. Radiographers and radiologists are not part of the judicial process and should therefore adopt a neutral position, preventing coercion by law enforcement bodies whilst at the same time remembering a duty both to public interest and to the suspect in protecting against unnecessary examination. The latter duty also includes the necessity to detect potentially dangerous packages in the
ABDOMINAL RADIOGRAPHYIN SUSPECTED 'BODY PACKERS' knowledge o f previous fatalities (Beltinger, 1980; Wetli and M i t t l e m a n , 1981). The effectiveness o f such a service is difficult to assess. We have h a d n o k n o w n false negatives b u t this c a n n o t be proven in a n y way. Freislederer et al. (1988) d e m o n strated experimentally that c o m p u t e d t o m o g r a p h y offers the highest rate of detection o f ingested packages b u t this m e t h o d is impracticable in the r o u t i n e m a n a g e m e n t of suspects. P r o b a b l y the most valuable c o n t r i b u t i o n a radiography service offers is that of a deterrent to organized, routine smuggling o f controlled substances. A series of successful detentions, detections and s u b s e q u e n t prosecutions of such a group, smuggling cocaine f r o m the c o n t i n e n t o f Africa, has resulted in the a p p a r e n t a b a n d o n m e n t o f M I A as a port of entry. It r e m a i n s the o p i n i o n of the radiologists c o n c e r n e d that this service is a valuable c o n t r i b u t i o n to society as a whole. Acknowledgements. l wish to thank Mrs Judy White for her help in research for this paper and Mrs Gwen Oliver for preparing this manuscript. REFERENCES
Beltinger,J (1980). Cocaine intoxication: massive oral overdose. Annals of Emergency Medicine, 9, 429 430. Craig, JOMC (1990). Editorial. Radiography of suspected drug smugglers. Clinical Radiology, 41,228.
325
Dassel, PM & Punjabi, E (1979). Ingested marihuana filled balloons. Gastroenterology, 76, 166 169. Dunne, JW (1983). Drug smuggling by internal bodily concealment. Medical Journal of Australia, 2, 436-439. Freed, TA, Sweet, LN & Gauder, PJ (1976). Balloon obturation bowel obstruction: a hazard of drug smuggling. American Journal of Roentgenology, 127, 1033-1034. Freislederer, A, Bautz, W & Schmidt, V (1988). Body-Packing: Wertigkeit moderner bildgebender Verfahren zum Nachweis inkorporierter Transportmedien. Archivefiir Kriminologie, 182, 145-153. ICRP (1991). 1990 Recommendations of the International Commission on Radiological Protection. ICRP Publication 60, Pergamon Press, Oxford. Lancashire, MJR, Legg, PK, Lowe, M, Davidson, SM & Ellis, BW (1988). Surgical aspects of international drug smuggling. British Medieal Journal, 296, 1035 1037. Lopez, HH Jr, Goldman, SM, Liberman, II & Barnes, DT (1974). Cannabis accidental peroral intoxication: the hashish smuggler roentgenographically unmasked. Journal of the American Medical Association, 227, 1041 1042. McCarron, MM & Wood, JD (1983). The cocaine 'body packer' syndrome-diagnosis and treatment. Journal of the American Medical Association, 250, 1417 1420. National Radiation Protection Board (NRPB) (1988). Guidance notes for the protection of persons against ionising radiations arising from medical and dental use. HMSO. Pagliuca, A & Mufti, GJ (1991). Warnings over cling film. British Medical Journal, 302, 593. Vowels, M & Harvey, P (1980). Ingestion of hashish oil filledcondoms. Medical Journal of Australia, 2, 509-510. Wetli, CV & Mittleman, RE (1981). The 'body packet syndrome' toxicity following ingestion of illicit drugs packed for transportation. Journal of Forensic Science, 26, 492 500.
