Massive Ingestion of Narcotic Packets: Not a Case for Endoscopic Intervention

Abstract

Introduction: Ingested packets of illicit narcotics is a rising phenomenon in drug-trafficking, often presented to GI service for endoscopic intervention. We present a case of massive ingestion of suspected cocaine packets where endoscopic management is not an option. Case Report: A 29-year-old female with unknown medical history, was brought to ER in severe respiratory distress. The patient was intubated, and soon after, developed seizure and ventricular tachycardia. Following resuscitation, work-up was initiated. Urine tested positive for cocaine. CT of the abdomen revealed multiple packets in the stomach, small intestine, colon, and vagina that were suspected to contain cocaine. Endoscopic intervention was deferred due to the risk of packet rupture, and instead, patient underwent emergent exploratory laparotomy with removal of packets of foreign bodies from the GI tract and vagina. Discussion: Foreign body ingestion is commonly seen in pediatric and adult populations. Although, the majority of foreign bodies swallowed tend to pass spontaneously, in certain cases urgent or emergent endoscopic intervention is indicated (e.g. ingestion of disc batteries, sharp objects, or where there is potential for bowel obstruction). Ingested packets of narcotics is a rising phenomenon in drug trafficking across borders, posing a special challenge. Radiographic studies can visualize these ingested packets, with CT imaging being most sensitive. There is a significant risk for intestinal obstruction, packet rupture, and death. While endoscopic extraction is an attractive modality; in this setting, along with the size, multiplicity, the uncertain nature of the contents, and the potential for rupture and leak of a massively toxic substance; such modality is not recommended. In our case, the large number of swallowed packets, with many already beyond the reach of conventional endoscopy, were grounds that argued against the temptation for endoscopic intervention. Conclusion: This case emphasized the concept that realizing the limitations of endoscopy is as important as understanding the proper timing and indications of endoscopic interventions.Figure 1: CT scan of the abdomen/pelvis with ingested packets.Figure 2: Surgically removed packets.