|Year : 2019 | Volume
| Issue : 3 | Page : 168-171
Single-needle celiac plexus block for pain management in a case of liver hemangioma
Department of Anaesthesiology, Dr. D Y Patil Medical College Hospital, Kolhapur, Maharashtra, India
|Date of Submission||30-Aug-2019|
|Date of Decision||06-Oct-2019|
|Date of Acceptance||04-Nov-2019|
|Date of Web Publication||5-Dec-2019|
Dr. Kalpana Kulkarni
Department of Anaesthesiology, Dr. D Y Patil Medical College Hospital, Kolhapur, Maharashtra
Source of Support: None, Conflict of Interest: None
Pain is the most common reason for presentation of a patient to a physician suffering from upper abdominal pathologies such as pancreatitis, benign tumors, or malignancies of liver/gall bladder/stomach/colon. Inflammation, scarring, and increased pancreatic duct pressure or malignant invasion of celiac plexus are the major causes of pain. A comprehensive evaluation of the patient for pain, associated pathological problem, and to find out any surgical indication is necessary. We present a 55-year-old female patient diagnosed of liver hemangioma with right upper abdominal pain. Treatment options of embolization under radiological guidance and/or surgical resection–enucleation were not acceptable and affordable to the patient. The patient was then referred for upper right intra-abdominal pain management. Following informed consent and vital monitoring inside the operation theater, the patient was given prone position. Under aseptic precautions and fluoroscopy guidance, diagnostic celiac plexus block was given on the right side with 5 ml of 2% lignocaine with adrenaline + 20 ml of 0.25% bupivacaine + fentanyl 25 μg at the level of L1 body of vertebra, which resulted in 80% of relief in pain for 18 h. Later, this was followed by neurolytic block using 15 ml of 8% phenol after injection of 10 ml of 0.25% bupivacaine to confirm the effective pain relief. Numerical Rating Scale score decreased from 7 to 2 at 1 week. Seventy-five percent of pain relief was present at the 6th month of follow-up. There was significant improvement in quality of life and sleep. Single-needle technique of celiac plexus block is a useful method for the control of chronic upper abdominal pain due to liver pathology.
Keywords: Celiac plexus block, chronic pain, liver hemangioma
|How to cite this article:|
Kulkarni K. Single-needle celiac plexus block for pain management in a case of liver hemangioma. Indian J Pain 2019;33:168-71
| Introduction|| |
Chronic abdominal pain due to pancreatic malignancies and chronic pancreatitis is severely debilitating, causing gross functional impairment that poorly responds to medical management with opioids and anti-inflammatory drugs. Liver hemangioma is one of the benign tumors in 4%–20% presenting with symptoms and pain. Transcatheter arterial embolization and/or surgical resection are the curative methods for giant hemangiomas (size >5 cm) causing symptoms. There is a need for alternative interventional therapy in case of failure of conservative management such as celiac plexus neurolysis to destroy selectively the plexus and block the visceral afferent nociceptor transmission for long-lasting pain relief in cases with liver/gastrointestinal malignancies or chronic conditions such as pancreatitis. Nociceptive signals from the viscera travels through celiac plexus to spinal cord to thalamus and cortex of the brain and perceived as pain. Different approaches and methods are used where success of neurolysis depends on the spread of solution in celiac area. Most commonly, celiac plexus neurolysis is performed either percutaneous computed tomography (CT)/fluoroscopic/ultrasonography (USG) guidance. However, recently, endoscopic ultrasound-guided anterior approach has been described for repeated blocks and continuous neurolysis. Temporary block is achieved twice with local anesthetic bupivacaine with addition of triamcinolone, but neurolysis with alcohol (50%–100%) or phenol (6%–10%) is preferred for long-lasting effect. Chemical neurolysis of celiac plexus is indicated mainly for control of chronic pain due to malignancies; however, in view of chronic right upper abdominal pain for 6 months in our case, with failure of conservative management, we opted for chemical celiac plexus neurolysis to have long-term pain relief.
| Case Report|| |
A 55-year-old female presented with a lump in the upper right hypochondriac region and pain since 6 months not relieved with medication. The lump grew gradually with increasing pain in the upper quadrant of the abdomen and referred to the back [Figure 1]. Pain increased with bodily movements, and on lying down, numerical rating scale (NRS) score was between 4 and 7. Pain was not associated with nausea or vomiting. She was evaluated and investigated for USG abdomen and CT scan that revealed a mass in the right lobe of the liver measuring 11 cm × 10 cm suggestive of hemangioma. Surgical and/or interventional radiological embolization treatment options were explained to the patient. In view of nonmalignant extensive surgery and refusal due to poor economic status, conservative line of management was adopted and she was referred for pain management. On examination, she was afebrile, no pallor/icterus, pulse rate of 88/min, and blood pressure of 140/90 mmHg. Chest was clear with normal heart sounds. The lump was detected in the right hypochondriac region with no abdominal rigidity or signs of ascites. Pharmacological treatment with oral analgesics and gabapentinoids was started, however had not much relief. Hence, a diagnostic followed by definitive chemical celiac plexus block was planned.
After obtaining informed consent for the procedure, right-sided diagnostic celiac plexus block was given in prone position. Vital monitoring was started. Preloading with 10 ml/kg Ringer's lactate was infused, and sedation was induced with midazolam 1 mg intravenous. A triangle was marked from T12 spinous process and at L1 level 7.5 cm laterally. Under aseptic precautions, local infiltration was done with 2% lignocaine at the distance of 7.5 cm laterally on the right side over the line at L1 vertebral spinous process. Under fluoroscopic guidance, a 15 cm 22G long spinal needle was inserted at 45° from horizontal to reach at anterolateral surface of L1 vertebra in the anteroposterior (AP) fluoroscopic view [Figure 2]. The needle was further advanced in the lateral view to reach 1 cm beyond the anterior border of L1 vertebra after negative aspiration test for blood or fluid. Test dose of 2% lignocaine with adrenaline 5 ml was injected followed by 20 ml of 0.25% bupivacaine + fentanyl 25 μg for the first two blocks. She had dramatic pain relief for 18 h with NRS score of 2. The block was repeated on the 3rd day followed by chemical neurolysis of celiac plexus performed on the 4th day. On the last occasion following negative aspiration test, 2 ml of Omnipaque dye was injected to check the needle position in the AP and lateral view [Figure 3] and [Figure 4]. Then, 10 ml of 0.25% bupivacaine was injected. After confirming the effect with reduction in pain, 15 ml of 8% phenol was injected under fluoroscopic guidance. The needle was flushed with 3 ml of normal saline before removal. The patient tolerated the procedure very well with stable vitals. No incidence of hypotension, tachycardia, or any adverse event occurred following block and in postblock period. The NRS score was <3 at 1 week and at 6 months of follow-up.
| Discussion|| |
The celiac plexus is made up of the right and left ganglia, surrounding the aorta at the level of celiac artery. It consists of visceral afferent as well as sympathetic and parasympathetic efferent fibers. Sympathetic nerve fibers run from the spinal cord to the sympathetic chain (T5-T12) and then synapse in the celiac ganglia that lies between T12-L2 level. In turn, pain from the foregut and midgut travels retrograde via parasympathetic visceral afferent nerve impulses from the celiac plexus through the splanchnic nerves to the central nervous system. Neurolytic treatment is directed at the celiac plexus, while a neurectomy is performed on the splanchnic nerves, either unilaterally or bilaterally.
The indications for celiac plexus neurolysis are cancer of pancreas, liver, spleen, kidneys, and GI malignancies and chronic pain of pancreatitis. The most common complications are orthostatic hypotension and diarrhea secondary to sympathetic blockade which is managed with fluid preloading and hydration. Other rare complications are bleeding-retroperitoneal hemorrhage due to inferior vena cava or puncture of aorta, pneumothorax, visceral injury, spinal, epidural injection, or local anesthetic toxicity.
Different approaches and methods of needle position are studied for improving success of the block by adequate spread around the celiac plexus. De Cicco M studied CT-guided single-needle neurolytic celiac plexus block by anterior approach in 138 cancer patients. The position of the needle was noted as caudad or cephalad to celiac artery, and the pattern of contrast spread was observed in four quadrants. In 58% of patients with cephalad needle position, the four-quadrant spread was higher and also the degree and duration of pain relief. Thus, it was concluded that single-needle technique is also good for obtaining wider spread, provided celiac area is not anatomically distorted. CT scan guidance offers advantage of precise location and depth of the needle, visualize celiac axis and its' distorted anatomy, vertebral body thus also prevents organ injury. It gives better evidence of final needle position.
In the absence of USG or CT scan, fluoroscopic guidance can be used with classical two-needle technique by posterior retrocrural approach for celiac plexus block. A method with the use of long-styleted needle is also studied for benign upper abdominal pain and intractable cancer pain management. Fluoroscopy-guided splanchnic nerve neurolysis in upper abdominal cancer with distorted celiac lymph node anatomy results in significant pain relief, reduces opioid consumption with improved quality of life have been observed by Ahmed and Arora. We utilized fluoroscopic-guided single long-styleted needle method on the right side for celiac plexus neurolysis in our patient with benign lesion of a hemangioma of the right lobe of the liver for the control of chronic distressing upper abdominal pain. The patient tolerated the procedure well with significant improvement in visual analog scale score and quality of life.
| Conclusion|| |
Celiac plexus neurolytic block using single-needle technique, as used by us, is an approachable way to relieve chronic pain symptoms due to benign condition such as liver hemangioma especially when conservative management has failed.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We acknowledge the support of D Y Patil Medical College and University while publishing this case study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]