Coeliac plexus block

Case Discussion:

A 54year old man with intractable visceral pain due to carcinoma of the head of pancreas on high dose opiods.

A anterior approach, percutaneous CT guided coeliac plexus block using 99% alcohol was performed in this patient with significant relief of pain and reducton in the dosage of analgesics.

Pain occurs frequently in patients with advanced cancers. Tumors originating from upper abdominal viscera such as pancreas, stomach,
duodenum, proximal small bowel, liver and biliary tract and from compressing enlarged lymph nodes can cause severe abdominal pain,
which do not respond satisfactorily to medical treatment.Percutaneous celiac ganglia block can be performed with high success and low complication rates under imaging guidance to obtain pain relief in patients with upper abdominal malignancies.Coeliac plexus block may also be effectively performed in patients with chronic pancreatitis for pain palliation with less effectiveness. Coeliac plexus block  can be performed through anterior or posterior approach under CT guidance depending on the operator’s preferences. The major advantage of the anterior approach is the reduced risk of neurologic complications because the tip of the needle is anterior to the spinal arteries and spinal canal. Other advantages of anterior approach are single puncture resulting in less discomfort to the patients, reduced procedure time and use of a smaller volume of neurolytic agent. It also avoids puncture of the aorta and permits
the patients to remain supine during the whole procedure. Initially celiac plexus blocks were performed blindly, in current practice ultrasound (US) and computed tomography (CT) are used to locate the exact level of the celiac artery origin. Coeliac Plexus block can be performed with the guidance from imaging techniques such as fluoroscopy and angiography aswell. Celiac ganglia are located anterior to the crura of the diaphragm, over the anterolateral wall of the aorta bilaterally, and just caudal to the level of the origin of the celiac artery. Twenty to fifty ml of ethanol
in concentrations of 50–100% is the most commonly used
neurolytic agent in clinical practice. Ethanol or phenol as nerve destructive agents and bupivacaine or lidocaine as local anesthetics have been used for coeliac plexus block in cancer patients. The degree of pain relief should be evaluated by using subjective and objective criteria. All patients should be interviewed before the procedure to obtain a baseline pain score for subjective criteria. Visual analog scale (range: 0–10) with
“0” corresponding no pain and “10” corresponding the worst pain might be used. Numbers and doses of pain medication are taken as objective criteria.Patients should be hydrated with normal saline for the risk of hypotension during or after the procedure.

Local posterior abdominal and back pain during or immediately after a celiac plexus block has been reported commonly because of the ablative effect of the neurolytic agent . Other common self-limiting complication is diarrhea occurs due to sympathetic blockade and unopposed parasympathetic efferent influence after the block, and usually resolves in around 48 hours. Orthostatic hypotension can be detected less commonly  due to loss of sympathetic tone and dilated abdominal
vasculature. It is usually transient (few hours) and can be managed with IV hydration. Neurologic complications such as paraplegia, leg weakness, sensory deficits, and paresthesias have been reported rarely.
Paraplegia was attributed to either direct injury of  the spinal cord during the procedure or to injection into the anterior spinal artery, which perfuses the lower two thirds of the spinal cord . Complications related to puncture of the liver, stomach, pancreas and bowels are rare. Other rare complications are impotance, gastroparesis, superior mesenteric
vein thrombosis, chylothorax, pneumothorax, chemical pericarditis, aortic pseudoaneurysm, aortic dissection, hemorrhage and retroperitoneal fibrosis.

Coeliac Plexus block under CT guidance is an easy and safely performed procedure with a high success and low complication rates for pain palliation in patients who have chronic abdominal pain related to celiac ganglia.

References:

Caraceni A, Portenoy KR. Pain management in patients with pancreatic
carcinoma. Cancer 1996;78:639–53.

Akhan O, Ozmen MN, Basgun N, et al. Long-term results of celiac ganglia block: correlation of grade of tumoral invasion and pain relief. Am J Roentgenol 2004;182:891–6.

Whiteman M, Rosenberg, Haskin P, Teplick S. Celiac plexus block for interventional radiology. Radiology 1986;161:831–6.

Romanelli DF, Beckmann CF, Heiss WF. Celiac plexus block: efficacy and safety of the anterior approach. Am J Roentgenol 1993;160:497–500.

Lee MJ, Mueller PR, van Sonnenberg E, et al. CT-guided celiac ganglion block with alcohol. Am J Roentgenol 1993;161:633–6.

Gimenez A, Martinez-Noguera A, Donoso L, Catala E, Serra R. percutaneous neurolysis of the celiac plexus via the anterior approach
with sonographic guidance. Am J Roentgenol 1993;161:1061–3.

Davies DD. Incidence of major complications of neurolytic celiac plexus block. J R Soc Med 1993;86:264–6.

Devrim Akinci, Okan Akhan.Celiac ganglia block. European Journal of Radiology 55 (2005) 355–361