Celiac plexus block: Side effects

Pain

Introduction

The celiac plexus is the largest plexus of the sympathetic nervous system. It contains preganglionic sympathetic fibers from greater and lesser splanchnic nerves (emerge from the thoracic sympathetic ganglia, T5 to T12 ) as well as postganglionic sympathetic and preganglionic parasympathetic fibers . It provides sensory innervation and sympathetic outflow to stomach, liver, spleen, pancreas, kidney and GI tract up to splenic flexure. Plexus is located at the level of T12-L2 (usually L1) and lies anterior to aorta in the retroperitoneal space.

Indications

Most common indication is treatment of pain caused by pancreatic cancer. Occasionally used in the treatment of pain from chronic pancreatitis (controversial). Can be used for pain from other GI malignancies from LES to splenic flexure, as well as liver, spleen and kidneys.

Complications

Orthostatic hypotension (most common, can be minimized with fluid hydration) and diarrhea (secondary to blockade of sympathetic fibers). Less common complications include paraplegia (from damage to artery of Adamkiewicz), local anesthetic toxicity, spinal or epidural injection, aortic or vena cava puncture and bleeding, retroperitoeneal hemorrhage, visceral organ injury, and pneumothorax (if needle is placed too cephalad) 

  • Anatomical Considerations: preganglionic SNS (greater/lesser splanchnic nerves), postganglionic SNS, preganglionic PNS, sensory
  • Indications: pancreatic cancer (common); sometimes pancreatitis (controversial)
  • Common Side Effects: orthostatic hypotension, diarrhea
  • Rare Side Effects: paraplegia, LA toxicity, spinal/epidural injection, aortic or vena cava puncture, retroperitoeneal hemorrhage, visceral organ injury, pneumothorax

Celiac plexus block and neurolysis can be useful for patients who have chronic abdominal pain from malignancies of the gastrointestinal tract, especially pancreatic cancer. The celiac plexus is made of the afferent fibers to the upper abdominal tract and sympathetic outflow from T5-T12. For diagnostic blocks, local anesthetic is used. For neurolysis, either phenol or ethanol is used. 

The procedure itself may have technical complications. Due to the close proximity of the aorta, celiac trunk and inferior vena cava, intravascular injections, vessel lacerations/dissections and hematomas have been documented, as well as pneumothoraces, renal injury, hematuria. Additionally, there are risks of deep abscess formation and blockade of unintended nerves such as the upper lumbar plexus, epidural or intrathecal spread. One of the most concerning possible complications is paraplegia, which may result from intrathecal spread of neurolytic agent or vasoconstriction of the great radicular artery. 

Expected side effects of the procedure are local soreness from the needle pass and possibly minor bruising. As this block is expected to result in a partial sympathectomy, hemodynamic responses to positional changes may be blunted leading to orthostatic hypotension. Furthermore, this sympathectomy leads to increased intestinal motility and diarrhea.

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