Celiac Plexus Block and Neurolysis in the Management of Chronic Upper Abdominal Pain

Abstract

Chronic upper abdominal pain occurs as a complication of various malignant and benign diseases including pancreatic cancer and chronic pancreatitis, and when present may contribute to lower quality of life and higher mortality. Though various pain management strategies are available as part of a multimodal approach, they are often incompletely effective and accompanied by side effects. Pain originating in upper abdominal viscera is transmitted through the celiac plexus, which is an autonomic plexus located in the retroperitoneum at the root of the celiac trunk. Direct intervention at the level of the plexus, referred to as celiac plexus block or neurolysis depending on the injectate, is a minimally invasive therapeutic strategy which has been demonstrated to decrease pain, improve function, and reduce opiate dependence. Various percutaneous techniques have been reported, but, with appropriate preprocedural planning, use of image guidance (usually computed tomography), and postprocedural care, the frequency and severity of complications is low and the success rate high regardless of approach. The main benefit of the intervention may be in reduced opiate dependence and opiate-associated side effects, which in turn improves quality of life. Celiac plexus block and neurolysis are safe and effective treatments for chronic upper abdominal pain and should be considered early in patients experiencing such symptoms.

Keywords: celiac plexus block; celiac plexus neurolysis; image-guided approach; interventional radiology; pain management; palliative care; pancreatic cancer.

Fig. 1

Bilateral posterior antecrural approach celiac plexus neurolysis performed in a 33-year-old man with metastatic pancreatic adenocarcinoma and intractable abdominal pain resulting in prolonged hospital admission. ( a ) Needle tips (arrows) were positioned immediately anterolateral to the aorta in the region of celiac trunk. ( b ) A small amount of dilute contrast (arrows) was injected through each needle to confirm position. ( c ) 30 mL of 100% ethanol (arrows) was then injected through each needle. The patient's pain subsequently improved and he was discharged home. He subsequently developed recurrent pain attributable to disease progression and returned for repeat neurolysis 6 months later (not shown).

Fig. 2

Bilateral posterior antecrural approach celiac plexus neurolysis performed in a 19-year-old female patient with median arcuate ligament syndrome (MALS) who had undergone surgical release 1 year prior to presentation and continued to experience intractable pain. She first underwent diagnostic celiac plexus block to confirm pain transmission through the plexus, and subsequently underwent neurolysis. ( a ) Needle tips (arrows) were positioned immediately anterolateral to the aorta at the level of the celiac trunk (dashed arrow). Dilute contrast was then injected to confirm position (not shown). ( b ) 5 mL of mepivacaine and 25 mL of 100% ethanol (arrows) were then injected into each needle. The patient's pain subsequently improved and she was discharged without complication.

Fig. 3

Bilateral posterior antecrural approach celiac plexus neurolysis performed in a 66-year-old female patient with locally advanced pancreatic adenocarcinoma and intractable abdominal pain. ( a ) Needle tips (arrows) were positioned immediately anterolateral to the aorta in the region of celiac trunk. ( b ) A small amount of dilute contrast (arrows) was injected through each needle to confirm position. ( c ) 5 mL of mepivacaine was injected into each needle followed by 100% ethanol, 35 mL on the right and 25 mL on the left. The needles were then flushed with 5 mL mepivacaine before removal.

Fig. 4

Unilateral posterior antecrural approach celiac plexus neurolysis performed in an 83-year-old female patient with chronic abdominal pain secondary to pancreatic adenocarcinoma. Severe scoliosis and kyphosis precluded a bilateral posterior approach, so unilateral neurolysis using a left posterior paravertebral route was performed. ( a ) Left-sided needle tip (arrow) was positioned anterolateral to the aorta in the region of celiac trunk. ( b ) A small amount of dilute contrast (arrow) was injected to confirm position. ( c ) The following medications were then injected in order: 10 mL of mepivacaine, 40 mL 100% ethanol, and an additional 10 mL of mepivacaine.