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BackTable / VI / Topic / Procedure
Celiac Plexus Block
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Pre-Procedure Prep
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
Pre-Procedural 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
Celiac Plexus Block Podcasts
Listen to leading physicians discuss celiac plexus block on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.
Procedure Steps
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
Post-Operative 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
Celiac Plexus Block Demos
Watch video walkthroughs of celiac plexus block on the BackTable VI expanded content network.
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
Disclaimer: The Materials available on https://www.BackTable.com/ are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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