Celiac Plexus Block

Lubdha M. Shah, MD

Key Facts

Terminology

Palliative procedure in cases of severe upper abdominal pain caused by pancreatitis or advanced cancers of the upper abdominal viscera, especially pancreatic cancer
- Blocks transmission of pain by treating CP with a neurolytic agent, such as alcohol
- Can be guided by bony landmarks, fluoroscopy, ultrasound, CT, MR, or endoscopic ultrasound
Abdominal visceral pain is mediated through nerve fibers that travel from viscera → celiac ganglia → splanchnic nerves

Procedure

Posterior (antero- or retrocrural) or anterior approach
CT guides accurate positioning of needle(s) in vicinity of CP while avoiding penetration or injection into spinal cord, major vascular structures, liver, kidneys, and bowel

Post-Procedure

Success of CPB is dependent on effective distribution of neurolytic agent throughout entire CP
In some cases, regional tumor infiltration or scar tissue and fibrosis can limit access to celiac plexus & prevent effective delivery of neurolytic agent

Outcomes

Complications
- Paraplegia
- Vascular injury
- Hypotension or diarrhea due to loss of sympathetic tone and splanchnic vasodilation/unopposed parasympathetic influence

Coronal graphic depicts the right

and left

celiac ganglia, superior mesenteric ganglion

, & splanchnic nerves (T5-T12)

. The CP extends from T12 to mid L2 and can be defunctionalized with neurolytic medications.

Axial NECT demonstrates needle tip with contrast in the sympathetic plexus ganglia

. CT outlines the anatomy & tumor burden; it allows precise needle placement & better delineation of injectate spread.

TERMINOLOGY

Abbreviations

Synonyms

Definitions

Palliative procedure in cases of severe upper abdominal pain caused by pancreatitis or advanced cancers of the upper abdominal viscera, especially pancreatic cancer
- Blocks transmission of pain by treating celiac plexus (CP) with a neurolytic agent, such as alcohol
- Can be guided by bony landmarks, fluoroscopy, ultrasound, CT, MR, or endoscopic ultrasound

Anatomy

Abdominal visceral pain is mediated through nerve fibers that travel from the viscera → celiac ganglia → splanchnic nerves
- CP: Autonomic efferents (supply upper abdominal viscera) & visceral afferents (supply abdominal viscera from distal esophagus to transverse colon)
- Block at ganglion level: Afferents innervating abdominal & pelvic organs travel in/along sympathetic nerves, trunks, ganglia, & rami
- Splanchnic nerve blocks will affect only sympathetic efferent and afferent pathways
CP consists of 1 to 5 pairs of ganglia ranging in size from 0.5-4.5 cm: The celiac, the aortic-renal, and the superior mesenteric
- Variable location of CP with regard to bony landmarks; more reliably found close to ostia of celiac artery
  - ˜ 0.6 cm caudad to celiac artery on right and 0.9 cm caudad to celiac artery on left
Retro- and anterocrural space is well-defined anatomic compartment that restricts spread of neurolytic agent
- 3 components: Aorta, crura of diaphragm, vertebral body

PRE-PROCEDURE

Indications

Severe chronic abdominal pain due to advanced cancers of the upper abdominal viscera, especially pancreatic cancer
- Blocking transmission of pain with a neurolytic agent, such as alcohol, can decrease the need for opiates and limit opioid side effects, especially constipation
- Alcohol destroys nerves by dissolving their fatty sheaths but has little effect on other nearby structures such as the muscular wall of the aorta

Contraindications