Celiac plexus block for visceral pain

Celiac Plexus Block and Neurolysis: A Review

Pain is often associated with chronic pancreatitis and pancreatic cancer. Often times opioids are used to treat pain; however, the use of opioids is frequently difficult. Endoscopic ultrasound-guided celiac plexus block and celiac plexus nuerolysis are safe and effective modalities used to alleviate pain. Celiac plexus block is a transient interruption of the plexus by local anesthetic, while celiac plexus neurolysis is prolonged interruption of the transmission of pain from the celiac plexus using chemical ablation. Celiac plexus block is generally performed in the unilateral position, while celiac plexus neurolysis is performed in the unilateral or bilateral position.

Pulse Transit Time as a Predictor of the Efficacy of a Celiac Plexus Block in Patients With Chronic Intractable Abdominal Pain

OBJECTIVE

There is no well-defined predictor of satisfactory pain relief after celiac plexus block (CPB) at the early stage of treatment. This study evaluated whether measurement of the electrocardiographic R-wave and the arrival time of the pulses at the toe pulse transit time (E-T PTT) can be an early predictor of pain response and success of CPB in patients with chronic intractable visceral pain.

METHODS

Twelve patients aged between 20 and 80 years who underwent CPB for treatment of chronic intractable cancer-related abdominal pain were included. A successful CPB was determined as a >50% decrease on the numerical rating scale measured 24 hours after the procedure. The E-T PTT at baseline and at 5, 10, 20, and 30 minutes after the injection of local anesthetic was measured as the time between the R-wave on the electrocardiogram and the peak point of the corresponding plethysmogram wave from the ipsilateral great toe. The change in the E-T PTT that was predictive of a successful CPB was analyzed using receiver operating characteristic curve analysis.

RESULTS

A CPB was successful in 9 of 12 cases; the dE-T PTT5/E-T PTT0 of the success group was 6.84%±5.04% versus 0.72%±0.78% in the failure group (P=0.021). The mean E-T PTTx differed significantly between timepoints (F=9.313, P=0.014) and between the success and failure groups (P<0.01). The best value of dE-T PTT5/E-T PTT0 indicating a successful CPB, estimated by receiver operating characteristic curve analysis, was 2.30% (sensitivity 88.9%, specificity 100%). The area under the curve was 96% (95% confidence interval, 85.7%-100%).

CONCLUSIONS

Prolongation of E-T PTT at 5 minutes after CPB correlates closely with a significant analgesic effect.

Pain management in chronic pancreatitis: taming the beast

Abdominal pain is a principal and in many cases, the only observable symptom of chronic pancreatitis. Like all chronic pain conditions, managing abdominal pain in chronic pancreatitis remains an onerous task for health care providers. Different mechanisms have been postulated in trying to better understand the pathogenesis of pain in chronic pancreatitis. This review seeks to take a broad look at the various options that are available to providers in trying to achieve pain relief and a better quality of life for chronic pancreatitis patients.

CT-guided celiac plexus neurolysis: a review of anatomy, indications, technique, and tips for successful treatment

The celiac plexus is the largest visceral plexus and is located deep in the retroperitoneum, over the anterolateral surface of the aorta and around the origin of the celiac trunk. It serves as a relay center for nociceptive impulses that originate from the upper abdominal viscera, from the stomach to the proximal transverse colon. Celiac plexus neurolysis, with agents such as ethanol, is an effective means of diminishing pain that arises from these structures. Percutaneous imaging-guided celiac plexus neurolysis has been established as an invaluable therapeutic option in the management of intractable abdominal pain in patients with upper abdominal malignancy. The use of multidetector computed tomography (CT) for imaging guidance has superseded other modalities and allows direct visualization of the spread of the neurolytic agent in the antecrural space. Accurate depiction of the retroperitoneal anatomy and the position of the needle tip helps avoid crucial anatomic structures such as the pancreas, aorta, celiac artery, and superior mesenteric artery. Proper patient education, meticulous preprocedure planning, use of optimal multidetector CT techniques, adjunctive CT maneuvers, and postprocedure care are integral to successful celiac plexus neurolysis. Celiac plexus neurolysis does not completely abolish pain; rather, it diminishes pain, helping to reduce opioid requirements and their related side effects and improving survival in patients with upper abdominal malignancy.

Assessment of celiac plexus block and neurolysis outcomes and technique in the management of refractory visceral cancer pain

OBJECTIVE

To assess demographic and clinical factors associated with celiac plexus neurolysis outcomes.

DESIGN

Retrospective clinical data analysis.

SETTING

A tertiary care, academic medical center.

PATIENTS

Forty-four patients with terminal visceral (mostly pancreatic) cancer who failed conservative measures. Interventions. Fifty celiac plexus alcohol neurolytic procedures done for pain control after a positive diagnostic block.

OUTCOME MEASURES

A successful treatment was predefined as >50% pain relief sustained for > or =1 month. The following variables were analyzed for their association with treatment outcome: age, gender, duration of pain, origin of tumor, opioid dose, type of radiological guidance used, single- vs double-needle approach, type of block (e.g., antero- vs retrocrural), immediate vs delayed neurolysis, volume of local anesthetic employed for both diagnostic and neurolytic blocks, and use of sedation.

RESULTS

Those variables correlated with a positive outcome included lower opioid dose and the absence of sedation. Strong trends for a positive association with outcome were found for the use of computed tomography (vs fluoroscopy), and using <20 mL of local anesthetic for the diagnostic block.

CONCLUSIONS

Celiac plexus neurolysis may provide intermediate pain relief to a significant percentage of cancer sufferers. Both careful selection of candidates based on clinical variables, and technical factors aimed at enhancing the specificity of blocks may lead to improved outcomes.

Coeliac plexus block in the management of chronic abdominal pain due to severe diabetic gastroparesis

Abdominal pain can be disabling in patients with gastroparesis. The pathogenesis of pain in these individuals is poorly understood. Agents commonly used in clinical practice, including tricyclic antidepressants, gabapentin, and pregabalin, have remained largely unsatisfactory in treating this pain. We report the case of a 50-year-old woman presenting with chronic unrelenting abdominal pain due to severe diabetic gastroparesis that was managed successfully with coeliac plexus block with local anaesthesia and steroid injection. Adequate analgesia was achieved and maintained for 10 weeks following the coeliac plexus block, which allowed elimination of opiate requirements for pain management (and avoidance of narcotic associated constipation), continuation of percutaneous endoscopy jejunostomy tube feedings, and avoidance of long term parenteral nutrition.

Neurolytic blocks revisited

The use of neurolytic blockade is a staple in the management of cancer pain. However, the data on neurolysis for chronic pain are plagued by inconsistencies in patient selection, diagnostic criteria, technical standards, and outcome measures. No one neurolytic agent or technique has been proven superior to another. Current evidence suggests that patients with pain of malignant origin may benefit from a variety of neurolytic techniques, as the benefit of documented short-term pain relief may outweigh risk at the end of life. In the absence of compelling data suggesting low-risk long-term efficacy, neurolysis for chronic benign pain should be cautiously considered, in most cases, only after failure of aggressive multidisciplinary management.