What is a celiac (coeliac) plexus block?

Celiac Plexus Block: Technique and Applications

A celiac plexus block is an interventional pain management procedure that targets the celiac plexus, a dense network of interconnected neural fibers surrounding the celiac artery as it branches from the aorta, to interrupt pain signals from the upper abdominal organs, particularly the pancreas. The procedure involves injecting either a neurolytic agent (alcohol or phenol) for permanent blockade or local anesthetic with steroids for temporary blockade into the celiac plexus to disrupt pain transmission from the upper abdominal viscera to the central nervous system. 1

Anatomical Target

• The celiac plexus is located at the level of T12-L1 vertebrae
• It transmits visceral sensory inputs (including pain signals) from most upper abdominal organs:
  • Pancreas
  • Liver
  • Gallbladder
  • Stomach
  • Ascending and transverse colon

Types of Celiac Plexus Blocks

1. Celiac Plexus Neurolysis (CPN)

   • Uses neurolytic agents (alcohol or phenol)
   • Creates permanent or long-lasting (3-6 months) blockade
   • Primarily for cancer pain, especially pancreatic cancer
   • Typically 10-20 mL of absolute ethanol is used 1

2. Celiac Plexus Block (CPB)

   • Uses local anesthetic with steroids
   • Creates temporary blockade
   • Used for diagnostic purposes or non-malignant conditions
   • Prophylactic antibiotics recommended when steroids are used 1

3. Celiac Ganglia Neurolysis (CGN)

   • Directly targets the celiac ganglia (visible on imaging)
   • Uses smaller volumes (1-2 mL) of neurolytic agent
   • More precise targeting than standard CPN 1

Approaches and Guidance Techniques

Several approaches can be used to perform a celiac plexus block:

1. Percutaneous approaches:

   • Posterior approach (most common)
   • Anterior approach
   • Guidance methods:
     • CT guidance
     • Fluoroscopy guidance
     • Ultrasound guidance
     • MRI guidance (less common) 2

2. Endoscopic approach:

   • EUS-guided (endoscopic ultrasound)
   • Performed through the stomach wall
   • Increasingly preferred due to real-time visualization 1

Primary Indications

1. Pancreatic cancer pain

   • Most established indication
   • Recommended for visceral pain from upper abdominal cancer
   • Provides significant advantage over standard analgesic therapy for up to 6 months 1
   • Success rate decreases with disease outside the pancreas 1

2. Other upper abdominal cancer pain

   • Used for visceral pain from other upper abdominal malignancies
   • Less evidence than for pancreatic cancer

3. Chronic pancreatitis

   • Not routinely recommended
   • Lower efficacy (51-59% vs 72-80% for cancer pain) 1
   • Should be considered only in selected patients with debilitating pain when other measures have failed 1

Efficacy

• For pancreatic cancer pain:

  • Pain relief in 70-80% of patients 1, 3
  • Reduces opioid consumption 3
  • Duration of effect typically 3-6 months 1

• For chronic pancreatitis:

  • Pain relief in 50-60% of patients 1
  • Duration of benefit typically less than 6 months 1
  • Less effective than for cancer pain 1

Timing of Intervention

Early CPN at the time of diagnosis is recommended for pancreatic cancer as it reduces pain and may moderate opioid consumption compared with best medical therapy alone 1.

Complications and Safety Considerations

Common side effects:

• Transient hypotension
• Diarrhea
• Local pain at injection site

Rare but serious complications:

• Pneumothorax
• Acute respiratory failure/ARDS 4
• Retroperitoneal hemorrhage
• Paraplegia
• Abscess formation (especially when steroids are used)

Clinical Decision Making

For patients with pancreatic cancer pain:

1. Consider CPN early in disease course
2. Use neurolytic agents (alcohol or phenol)
3. EUS-guided approach is recommended over percutaneous techniques 1
4. CGN (targeting visible ganglia) is recommended over standard CPN for improved pain relief 1

For patients with chronic pancreatitis:

1. Not routinely recommended
2. Consider only after failure of conventional pain management
3. Perform temporary block with local anesthetic first to assess potential benefit
4. Discuss limited efficacy and procedural risks with patient 1

Key Practice Points

• Celiac plexus block should be part of a multimodal pain management strategy, not used in isolation 1
• Neurolytic blocks should be limited to patients with short life expectancy 1
• For pancreatic cancer, CPN appears safe and effective with significant advantage over standard analgesic therapy 1
• Repeated injections for chronic pancreatitis should be avoided to prevent major complications 1
• Phenol may be used instead of alcohol in patients with alcohol intolerance 1

The celiac plexus block represents an important interventional option for managing visceral pain, particularly in pancreatic cancer, where it can significantly improve quality of life and reduce opioid requirements.