L'OCCLUSIONE INTESTINALE NELLA COCAINE-PACKET INGESTION

During the last decade, the increase of drug traffic and close customs' control have led smugglers to attempt various methods to pass through customs undetected. One method is the ingestion of large numbers of drug-filled packets (usually containing cocaine), together with anticholinergics inhibiting intestinal peristalsis, by a smuggler, called 'bodypacker' or 'mule'. The up-to-date approach to cocaine-packet ingestion is conservative medical management during the spontaneous evacuation of the 'ovules'. Emergency surgical treatment should be reserved for the complications of cocaine-packet ingestion ('body packer syndrome'), which are bowel obstruction due to clustering of the containers and intraluminal rupture of the 'ovules' with massive drug transmucous absorption (acute cocaine intoxication). We describe a case of cocaine-packet ingestion in a 19 year old man who was asymptomatic at admission and thus conservatively treated. During the spontaneous evacuation of ovules, clinical and radiological signs of bowel obstruction appeared and the patient underwent emergency laparotomy with removal of 21 containers, two of them clustered in the distal ileum, causing the occlusion. This case gave reasons for a discussion on the specific features of bowel obstruction in cocaine packet ingestion. The bowel obstruction of cocaine-packet ingestion should be carefully considered and promptly treated because of the potentially lethal consequences (death rate of 56% of cases) of transmucous absorption of cocaine contained in 'ovules'. In fact, while opioid intoxication can be fought with specific antagonists towards opioid receptors (naloxone), the lack of a specific antidote makes cocaine poisoning particularly dangerous. Cocaine toxicity, that is mainly characterized by neuropsychical alterations, seizures, clonic-tonic convulsion, emesis, respiratory depression, arrhythmias and myocardium depression, marked mydriasis and hyperpyrexia, can be partially reduced with high dosages of chlorpromazine, propanolol and benzodiazepine (diazepam). Transmucous absorption is quick and massive, and it is favoured by conditions of phlogosis. The lethal dose per os is 1200 mg and the LD ₅₀ is 500 mg. These considerations stress the high risk of acute cocaine intoxication with potentially lethal progression for the breakage of even one ingested container, considering the remarkable quantity of cocaine in each 'ovule' (about 5-10 grams). The risk of rupture is strictly related to the structural features of the bags, on account of their different sensibility to the lithic action of gastroenteric secretions. Cocaine may also leak through the integral container, when the shells are partially permeable. Some authors have classified the 'ovules' into three different types, according to their morphology, structural features and related risk of breakage or leakage of the drug. The first type is characterized by greater risk of breakage or leakage. We recommend careful clinical control and a thorough assessment of whatever lesions in the ovules evacuated by the body-packers of the first type, since every death reported in the literature occurred in smugglers who had ingested first type cocaine containers. In our patient 'ovules' belonged to the second type, with low risk of breakage and leakage. It made it possible to carry on the conservative medical management after the first symptoms of bowel obstruction arose. Intestinal obstruction causes a prolonged exposure time to the lithic action of gastroenteric secretions and hyperperistaltism may increase the risk of mechanical rupture of 'ovules'. In this condition the intraluminal breakage of the containers is followed by a massive transmucous absorption, favoured by the increased permeability of enteric mucosa. Conservative management during the spontaneous evacuation of the 'ovules' therefore requires the close control of either initial over-dose symptoms or clinical and radiological signs of bowel obstruction, that makes mandatory prompt emergency laparotomy to remove the ovules from the gastroenteric tract, as in our case.