Celiac Plexus Block

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Pre-Procedure

Indications:
• Intractable abdominal pain
• Often from upper abdominal malignancy: pancreatic, gastric, esophageal, metastatic liver and retroperitoneal lymphadenopathy
• Chronic pancreatitis
• Severe nausea and vomiting in pancreatic malignancy

Contraindications:
• Uncorrectable bleeding diathesis
• Uncontrolled abdominal infection or sepsis
• Bowel obstruction

Preprocedural evaluation:
• H&P
• Detailed description of pain including location and severity
• Opportunity to set expectations with patient and family
• Discuss goals of therapy with patient
• Procedure shown to decrease opioid dependence and thereby reducing associated side effects
• Review cross sectional imaging for procedure planning
• Labs: Platelets and INR

Procedure

Position: anterior approach vs posterior approach with many options for needle placement
• Often, anatomy and pathology will dictate approach
• Most common is bilateral antecrural
• Bilateral vs unilateral
• Antecrural vs retrocrural
Posterior approach: patient will be prone or decubitus
Anterior approach: patient will be supine. Often times can obtain good neurolytic coverage with single needle placement

Imaging guidance:
• CT
• US
• US with fluoroscopy and/or cone beam CT

Needle: 20-22 g Chiba (Cook) or spinal needle
• Removable inner stylet
• Beveled tip for steering

See articles for target and optimal needle position

Once needle is in appropriate position
• Remove stylet and confirm no backflow of blood
• Inject ~5 mL of dilute contrast (1:50 of contrast:saline) to confirm position; contrast should diffuse freely in antecrural space vs retrocrural (more confined) space

Inject neurolytic
• 50-100% ethanol: recommend 95-100%
• 3-20% phenol (less common)
• Can mix with bupivacaine and contrast
• Volume of neurolytic can vary with approach and anatomy: 10-60 ml of neurolytic
• Can administer higher volume with antecrural approach
• Example of mixture: 20 mL ethanol 100%, 8 ml bupivacaine 0.25% and 2 ml contrast - inject 30 ml per side
• Inject slowly with approximately 30 mL delivered over 2 minutes. Should not have resistance during injection
• Flush needle with saline before removal

Tips:
• Attach 30 ml syringe with neurolytic to 3 way stopcock
• Deliver neurolytic with 5-10 mL syringe for better control
• Use mini-bore connection tubing to reduce risk of needle displacement during injection
• Can intermittently check with CT or cone beam CT to evaluate for neurolytic coverage during injection

Post-Procedure

Postoperative Care:
• Observation for 12-24 hours
• At risk patients: elderly, poor physical condition, poor nutritional status
• IV fluids
• Bedrest for 12 hours
• Telemetry or vital signs Q1 hour for 12 hours

Post-operative issues:
• Orthostatic hypotension
• Diarrhea
• Injury to nearby adjacent structures during procedure: vascular injury, bowel injury, pneumothorax
• Back and shoulder pain are common immediate postprocedural complaints

Follow-up:
• Assess patient's VAS (Visual Analogue Scale) 1 day, 1 week and 1 month following procedure
• In many patient's, procedure can safely be repeated if pain symptoms return

Related Procedures

No related procedures.

Step-by-step guidance on how to perform Mesenteric Stenting. Review tools, techniques, pearls, and pitfalls on the BackTable Web App.
 

References

[1] Mohamed RE, Mohamed AA, Omar HM. Computed tomography-guided celiac plexus neurolysis for intractable pain of unresectable pancreatic cancer. The Egyptian Journal of Radiology and Nuclear Medicine. 2017 Sept; 48, (3):627-637. doi: 10.1016/j.ejrnm.2017.03.027
[2] Nitschke AM, Ray CE Jr. Percutaneous neurolytic celiac plexus block. Semin Intervent Radiol. 2013;30(3):318‐321. doi:10.1055/s-0033-1353485
[3] Kambadakone A, Thabet A, Gervais DA, Mueller PR, Arellano RS. CT-guided celiac plexus neurolysis: a review of anatomy, indications, technique, and tips for successful treatment. Radiographics. 2011;31(6):1599‐1621. doi:10.1148/rg.316115526
[4] Arcidiacono PG, Calori G, Carrara S, McNicol ED, Testoni PA. Celiac plexus block for pancreatic cancer pain in adults. Cochrane Database Syst Rev. 2011;2011(3):CD007519. Published 2011 Mar 16. doi:10.1002/14651858.CD007519.pub2

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Celiac Plexus Block With Dr. Kris Schramm

Dr. Kris Schramm walks through a celiac plexus block, including a pre-procedure briefing.

 

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RadioGraphics (Oct 2011)

CT-Guided Celiac Plexus Neurolysis: a Review of Anatomy, Indications, Technique, and Tips for Successful Treatment

In this review article, we describe the celiac plexus anatomy and the indications, contraindications, techniques, and complications of CT-guided celiac plexus neurolysis, as well as various tips to ensure a successful outcome.

The Egyptian Journal of Radiology and Nuclear Medicine (Sep 2017)

CT-Guided Celiac Plexus Neurolysis for Intractable Pain of Unresectable Pancreatic Cancer

This study explores the value of CT-guided celiac plexus neurolysis (CPN) using the anterior median approach and single puncture technique with ethanol injection as palliative treatment for alleviating intractable pain in patients with unresectable pancreatic cancer.

Seminars in Interventional Radiology (Sep 2013)

Percutaneous Neurolytic Celiac Plexus Block

Patient selection and technial approach to percutaneous neurolytic celiac plexus block (PNCPB) as treatment for patients with intractable abdominal pain.

 

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