Coeliac plexus block

Question 1

What are the indications for a coeliac plexus block?

Answer 1

It is indicated in the management of malignant and non-malignant chronic
pain.

In the non-malignant setting it has been used successfully in patients with
acute and chronic pancreatitis.

In patients with cancer it is used particularly with upper abdominal tumours
that have a significant visceral component to their pain, e.g.

1. Pancreatic carcinoma
2. Retroperitoneal metastasis
3. Colon or stomach cancer
4. Capsular distension of the liver or spleen.

Question 2

What are the benefits of coeliac plexus block in malignant pain?

Answer 2

Reduction in systemic opiate consumption resulting in
decreased nausea,
constipation,
sedation
and increased appetite.
.
There is evidence that the use of high-dose opioids
may have a negative effect on immunity
and that utilising neurolytic blocks may have a survival advantage

Question 3

How would you perform this procedure?

Answer 3

Take informed Take informed consent and, as with all major nerve blocks, secure
intravenous access and the help of a skilled assistant.

There are three approaches:
1. The retrocrural (classic) approach
2. The anterocrural approach
3. Neurolysis of the splanchnic nerves

The needle is inserted at the level of the first lumbar vertebra, 5–7 cm from
the midline.

The tip of the needle is then directed toward the body of L1 for the
retrocrural and anterocrural approaches and to the body of T12 for
neurolysis of the splanchnic nerves.

CT and ultrasound facilitate a transabdominal approach in patients who are
unable to tolerate either the prone or lateral decubitus position or if the
liver is so enlarged that a posterior approach is not feasible.

Question 4

What are the complications of a coeliac plexus block?

Answer 4

1. Orthostatic hypotension is described in 1%–3% of patients and may occur
   for up to 5 days post-procedure
   - Treatment consists of bed rest, fluid replacement and avoidance of sudden
   changes in position. This side effect disappears when compensatory vascular
   changes are fully activated.
2. Other less common side effects include
   transient diarrhoea
   (treated with hydration and antidiarrhoeal agents, e.g. oral loperamide),
   dysaesthesia,
   interscapular pain,
   reactive pleurisy,
   hiccoughing and haematuria.
3. Rare but important complications are paraplegia (due to spasm of the
   lumbar segmental arteries or direct vascular/neurological injury) and bowel
   dysfunction, occurring in 1:683 neurolytic coeliac plexus blocks.

Question 5

What substances would you inject and at what doses?

Answer 5

For neurolytic blocks 20 ml of 50%–100% alcohol per side is utilised.

Bupivacaine 0.25% (5–10 ml) is injected prior to the alcohol,
which can result in severe pain on injection.

Phenol as a 10% formulation may be used
and has the advantage of being painless on injection.