To the Editor:Recently at the New Jersey Poison Center, we consulted on a patient who swallowed packets of heroin to evade law enforcement and was admitted to the hospital for whole bowel irrigation with polyethylene glycol solution. After 24 hours, the packets were still in the stomach, and disagreement arose within the treatment team based on “Management of ingested foreign bodies and food impactions” from the American Society for Gastrointestinal Endoscopy,1Ikenberry S.O. Jue T.L. Anderson M.A. et al.ASGE Standards of Practice Committee
Management of ingested foreign bodies and food impactions. which recommends against endoscopic packet retrieval and for surgical intervention if packets fail to progress. Our patient underwent endoscopic removal of several heroin packets, in consideration of 2 key factors: the circumstances of packet ingestion and the contents of the packets themselves.There are 2 distinct scenarios in which patients ingest concealed packets of illicit drugs. “Body packing” refers to the ingestion of many large-volume, well-constructed packets to smuggle the contents across secure borders.2Traub S.J. Hoffman R.S. Nelson L.S. Body packing—the internal concealment of illicit drugs. “Body stuffing” describes the hasty ingestion of a smaller number of poorly secured, low-volume packets to evade law enforcement. Although these low-volume packets are more likely to leak, they are much less likely to cause death because the total drug content is lower. These patients can undergo a trial of polyethylene glycol and, if packets fail to progress, controlled endoscopic removal.Unfortunately, the stark distinction between stuffing and packing is often overlooked in the literature leading to unintended misguidance.2Traub S.J. Hoffman R.S. Nelson L.S. Body packing—the internal concealment of illicit drugs. In addition, whether the packet contains an opioid or cocaine is significant. Although even a large opioid overdose can be effectively treated with naloxone and supportive care,3Beno S. Calello D. Baluffi A. et al.Pediatric body packing: drug smuggling reaches a new low. rupture of a large-volume packet of cocaine can be fatal. Endoscopy is usually appropriate for removal of heroin packets of either type that fail to progress from the stomach after a reasonable period (24-48 hours). Endoscopic removal is also reasonable for cocaine packets of either type but is best performed in a critical care setting with surgical backup. In either case, endoscopic technique should minimize trauma, such as with use of a basket or net rather than a grasping device.

The original guidance, published in 2011, could benefit from a focused update on these aspects of packet ingestion.

Disclosure

Both authors disclosed no financial relationships.

ReferencesIkenberry S.O. Jue T.L. Anderson M.A. et al.ASGE Standards of Practice Committee

Management of ingested foreign bodies and food impactions.

Gastrointest Endosc. 73: 1085-1091Traub S.J. Hoffman R.S. Nelson L.S.

Body packing—the internal concealment of illicit drugs.

N Engl J Med. 349: 2519-2526Beno S. Calello D. Baluffi A. et al.

Pediatric body packing: drug smuggling reaches a new low.

Pediatr Emerg Care. 21: 744-746Article InfoIdentification

DOI: https://doi.org/10.1016/j.gie.2020.12.052

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© 2021 by the American Society for Gastrointestinal Endoscopy

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Gastrointestinal EndoscopyVol. 73Issue 6

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This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, a search of the medical literature was performed by using PubMed. Studies or reports that described fewer than 10 patients were excluded from analysis if multiple series with more than 10 patients addressing the same issue were available. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants.

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Gastrointestinal EndoscopyVol. 94Issue 1

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We appreciate the interest taken by Calello et al1 in the American Society for Gastrointestinal Endoscopy (ASGE) guideline on management of ingested foreign bodies and food impactions.2 In their letter, the authors highlight 2 distinct scenarios of illicit drug packet ingestion: body packing and body stuffing. The authors highlight a case of successful endoscopic removal of several heroin packets from a patient. On the basis of their clinical experience, the authors conclude that endoscopy is appropriate for the removal of heroin packets and may be considered for the removal of cocaine packets in a critical care setting with surgical backup.

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