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

Abstract

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.

Figure 1

Gastric scintigraphy. The scintiscan was obtained after ingestion of a standard, solid, radiolabelled meal in December 2007. The white areas represent the isotope and the white outlines indicate the region of interest for quantification of radioactivity in the stomach. The percentage of solid food consumed that was emptied from the stomach at each time point after the meal is indicated below. There is notably delayed gastric and small bowel transit.

Figure 2

Coeliac plexus block with local anaesthetic and steroid (A) anteroposterior and (B) lateral radiographs. Using fluoroscopy, the L1 vertebral body was identified, and entry points approximately 4 cm lateral to the caudal end plate and below the 12th rib were marked. A 22 gauge, 3.5 inch spinal needle was inserted and advanced incrementally with fluoroscopic guidance into the mid body of the L1 vertebral body bilaterally. 10 ml of 0.25% bupivacaine mixed with 10 mg of triamcinolone was injected to the right; 6 ml of 0.5% bupivacaine mixed with 20 mg of triamcinolone was injected to the left.