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Celiac Plexus Block

If you are suffering from flank, back and/or abdominal pain that is a result of pancreatic cancer or pancreatitis, this procedure can offer you profound pain relief almost immediately.

What is a Celiac Plexus Block?

A celiac plexus block is a commonly performed treatment for individuals suffering from abdominal and/or flank pain that has been cause by cancer. While most often used for pain secondary to pancreatic cancer, the target for this procedure (the celiac plexus) provides innervation for a large number of other structures in the abdomen, making the celiac plexus block ideal for a number of other painful conditions as well.

The celiac plexus is a small region in the upper part of the gut responsible for transmitting pain when there has been damage to organs or a tumor in the area.  By “blocking” the celiac plexus, pain is stopped at the source. This can potentially eliminate the need for medications.

Indications

The first celiac plexus block was performed almost 20 years ago and was originally invented for patients with severe pain secondary to pancreatic cancer.  The procedure has since been perfected and is now used for a variety conditions:

Celiac Plexus Block  Treatment of visceral, poorly localized, abdominal pain, with or without malignancy
 Diagnostic block to differentiate somatic vs. visceral complaints
 Pancreatic cancer[1]
 Cholangiocarcinoma[1]
 Abdominal visceral pain syndrome
 Upper abdominal malignancies[2]
 Retroperitoneal malignancies
 Hepatobiliary disorders, including biliary sphincteric disorder
 Abdominal angina
 Pancreatitis, acute or chronic

What Are The Benefits?

Celiac plexus blocks are highly useful in diagnosing and treating upper abdominal pain. They can be performed to help separate out visceral from somatic pains, and be used as a treatment for cancer-related and non-cancer related pain. This procedure is extremely successful in treating the pain associated with upper abdominal cancer pain and should therefore be considered early on in the treatment algorithm.[2]   

Given the large amount of innervation from the gut that passes through the CP, this procedure is an ideal choice for treating abdominal pain, as your physician will need to know exactly what organ or pathway is involved. A celiac plexus block lacks specificity and can treat multiple areas simultaneously.

How Does It Work?

autonomic nervous sympatheticThis procedure is a variation of the sympathetic block that targets a region of the Sympathetic Nervous System (SNS) known as the Celiac (coeliac) Plexus (CP). The CP is a group of 1-5 ganglia of varying sizes located in the upper abdomen anterolateral to the aorta at the level of the 1st lumbar vertebrae. The ganglia are interconnected by a dense mesh-like network of neural fibers and carry afferent innervation from:

 Upper abdominal viscera
 Distal esophagus
 Stomach to the mid-transverse colon
 Pancreas
 Kidneys
 Gall bladder
 Adrenals
 Portions of the small bowel
 Liver

Learn More About the Sympathetic Nervous System

More Details

SNS diagramThe innervation of visceral abdominal structures largely comes from the sympathetic terminals of T5 –T12. The preganglionic fibers leave the spine with the exiting nerve root and travel with the white communicating rami to the level of the celiac ganglion. The greater splanchnic nerves (T5-T9) lesser splanchnic nerves (T10-11) and least splanchnic nerves (T11-12) travel along the lateral border of the thoracic vertebral body and dive anterior through crus of the diaphragm to become the celiac ganglion. The greater, lesser, and least splanchnic nerves travel together to become the CP.

The CP lies anterior to the vertebral body interspace at approximately T12 to L1, and usually lies near the take off of the Celiac and Superior mesenteric artery, which can be visualized on a preoperative Computerized Topography (CT) scan.

How Many Treatments Will I Need?

The first step in the procedure is the diagnostic block to test and see how much pain, if any, is being transmitted through the celiac plexus.  If this diagnostic block is successful and the pain is temporarily relieved, then you will be scheduled for the therapeutic portion of the procedure.  Typically, patients need only session to feel significant relief.

When Will I Feel Better?

After the diagnostic block, patients will report relief almost immediately. Typically, the cessation of pain lasts a few hours and then wears off. THIS IS NORMAL as the local anesthetic has a relatively short lifespan of just 6 to 8 hours.  After the anesthetic runs it’s course, the pain relief should start up again within a few hours. It may take up to 2 to 3 days to be noticeable.

Is a Celiac Plexus Block Right for Me?

If you suffer from pain that has failed to resolve with medications, this treatment may be an option for you.  A celiac plexus block should be performed under the strict supervision of a board-certified pain management specialist.

Contact the Ainsworth Institute to set up an initial evaluation to find out if you are a candidate for a celiac plexus block.

Procedure - Patient Details

A celiac plexus block can be performed a number of ways. The most popular way is the classic retrocural approach via fluoroscopy in the prone position using two needles. This technique is typically performed under local anesthetic, although IV sedation can be provided in certain instances when patients are unable to lie on their abdomen (prone).

Before starting, your skin will be cleaned with sterile soap to minimize the risk of infection. You physician then identify the target entry points on your skin by using the fluoroscopic C-arm, as well as identifying the target end points where the CP is located. These areas will be numbed with local anesthetic to make the procedure as painless as possible. Then, two thin needles are inserted with the aid of fluoroscopy and advanced to the location of the CP – one on either side of it. Once the needles are in correct position, a small amount of contrast will be injected to ensure the needles are correctly and safely situated. Once their position is confirmed, a small amount of local anesthetic will be injected to complete the procedure.

Profound pain relief marks a successful block, and depending on the type of anesthetic or agent injected, the relief can take effect in a matter of minutes. Much like other sympathetic blocks, a diagnostic block typically precedes a therapeutic block.

•  Diagnostic Block – A small amount of local anesthetic, like Lidocaine or Bupivacaine, is first injected to test the patient’s response to a blockade of the CP.

•  Therapeutic Block – In individuals with a positive response to the diagnostic block (i.e. a decrease in pain), the therapeutic block will follow with the administration of a neurolytic agent (i.e. dehydrated alcohol or phenol).

In those individuals with pain due to cancer, the diagnostic block may be omitted and your physician will likely proceed directly to the therapeutic block.

The entire procedure takes 20 to 30 minutes to complete. Once completed, two small dressings will be placed on your back and you will be transferred to the recovery area.

Risk Factors

Complications with a celiac plexus block are rare and are typically related to the technique used. A prospective, randomized study of 61 patients with pancreatic cancer, Ischia et al [3] compared the incidence of complications associated with the different conventional approaches to celiac plexus neurolysis (a therapeutic celiac plexus block). Orthostatic hypotension (position-related low blood pressure) was more frequent in patients who had a retrocrural (50%) or splanchnic nerve block technique (52%) than those individuals who underwent an anterocrural approach (10%). By comparison, transient diarrhea was more common in those patients who had an anterocrural approach (65%) than those who had a splanchnic nerve block technique (5%). The incidence of dysesthesia, interscapular back pain, hiccoughing, or hematuria was comparable amongst all three.

The incidence of overall complications from a neurolytic celiac plexus block was determined to be approximately 1 in 683 procedures.[4]  These complications included paraplegia and incontinence. Other potential complications include abdominal cramping and/or diarrhea, dizziness, weakness, hematuria, shortness of breath, fever, bleeding and numbness.

Other potential concerns are related to the underlying illness causing pain, i.e. cancer. Immunocompromised patients are potentially at high risk for infection; this is of particular relevance in patients with malignancy. Patients with metastatic cancer pain may have local masses in the region that may block the path of the needle. Lastly, those individuals receiving chemotherapy may have underlying thrombocytopenia that would put them at risk of increased bleeding and retroperitoneal hematoma.

Evidence of Performance

Celiac plexus blocks are a well-established treatment modality for treating abdominal and flank pain from a variety of causes, most importantly from cancer of the pancreas, liver, gall bladder, kidneys and upper digestive tract. There are 4 randomized controlled trials studying the efficacy of therapeutic celiac blocks (neurolysis).

In the study by Ischia, 48% reported a complete relief in their pain subsequent to their treatment with celiac plexus neurolysis, while 52% required additional therapeutic support.[3]  Technical failure was attributed to half of those not responding, and the other half were found to have neuropathic/somatic pain – this explaining why they may not have responded. In another of the randomized, controlled trials, the authors compared celiac plexus blocks to oral pain medication.[5]  The authors concluded the procedure was equal in efficacy to an oral opioid/NSAID’s medication regimen. More importantly, those treated with a celiac plexus block were noted to require significantly less pain medication and medication side effects were significantly higher in the medication-only group as compared to the procedure group.

The third randomized controlled trial compared drug therapy to celiac plexus blocks.[6]  The authors reported the celiac plexus block was associated with better short-term pain relief, lower analgesic consumption and fewer side effects such as nausea, vomiting, and constipation. The fourth trial compared the block to a sham procedure in 100 patients.[7]  The authors reported a significant decrease in pain in the procedure group at 6 weeks compared to the sham group.

In a published meta-analysis that evaluated the results of 21 retrospective studies in 1145 patients, the authors concluded that celiac plexus blocks were capable of achieving excellent pain relief in 89% of the patients during the first 2 weeks after the block.[8] The authors went on to describe that partial to complete pain relief persisted in 90% of patient still alive at the 3-month interval.

The Ainsworth Institute is Here to Help

If you are suffering from abdominal or flank pain, contact the Ainsworth Institute of Pain Management and schedule an appointment with one our board certified pain management specialists to learn more about this exciting treatment option.

References

[1] Fishman SM, Ballantyne JC, Rathmell JP, Bonica’s Management of Pain, 4th ed. Baltimore, Lippincott, 2010.

[2] de Oliveira R, dos Reis MP, Prado WA, The effects of early or late neurolytic sympathetic plexus blocks on the management of abdominal or pelvic cancer pain. Pain 2004; 1110: 400-408.

[3] Ischia S, Ischia A, Polati E, et al.: Three posterior percutaneous celiac plexus block techniques. A prospective randomized study in 61 patients with pancreatic cancer pain Anesthesiology. 1992; 76:534-540.

[4] Davis DD: Incidence of major complications of neurolytic coeliac plexus block. J R Soc Med. 1993; 86:264-266.

[5] Mercadante S: Celiac plexus block versus analgesics in pancreatic cancer pain. Pain. 1993; 52:187-192.

[6] Polati E, Finco G, Gottin L, et al.: Prospective randomized double-blind trial of neurolytic coeliac plexus block in patients with pancreatic cancer. Br J Surg. 1998; 85:199-201.

[7] Wong GY, Schroeder DR, Carns PE, et al.: Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer. a randomized controlled trial JAMA. 2004; 291:1092-1099.

[8] Eisenberg E, Carr DB, Chalmers TC: Neurolytic celiac plexus block for the treatment of cancer pain. A meta-analysis Anesth Analg. 1995; 80:290-295.

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