AND ANALGESIA.. Current Researches VOL.
ANESTHESIA . 1977
56,No.1,JAN.-FEB., 1
GALE E. THOMPSON, M D "
DANIEL C. MOORE, M D t
L. DONALD BRIDENBAUGH, M D $
ROBERT Y. ARTIN, MDS
Seattle, Washington 1
Alcohol celiac plexus nerve blocks were done in recurrent pain. Life duration ranged from 2
100 patients, of whom 97 had intractable ab- days to 14 months after the block. Complica-
dominal pain from cancer. In most cases, a n tions and side effects were infrequently seen
initial diagnostic block with bupivacaine was but did include a 10 percent incidence of pos-
followed by the therapeutic block performed by tural hypotension and 1 case of partial leg
injecting 50 ml of 50 percent ethyl alcohol. Good paralysis. This block is remarkably safe as
to excellent pain relief occurred in 94 percent well as effective and should be employed more
of patients. Fourteen blocks were repeated f o r frequently.
P AIN is a common complaint of patients
suffering from carcinoma in the upper
abdomen. The primary disease is often not
was 63.7 years. Fifty-five were males and
45 were females. Three patients had benign
disease with a diagnosis of chronic pancre-
amenable to surgery, radiation therapy, or atitis. Ninety-seven had carcinoma found
chemotherapy, and palliation becomes the by Iaparotomy or by percutaneous biopsy
major goal of treatment. Here is a situation (table 1).A variety of signs and symptoms
where the anesthesiologist can use a thera- heralded the onset of these malignancies.
peutic nerve block with consistently good Weight loss on the order of 3.6 to 6.8 kg was
results. Regardless of the kind of carcinoma found in 90 percent of the patients before
which precipitates abdominal discomfort, they sought medical assistance. The maxi-
there is a need to deal promptly with the mum weight loss was 21.3 kg. Jaundice was
situation. Life expectancy after the time of seen in 72 patients a t some time during the
diagnosis is generally less than 6 months. course of their disease. Pain was the major
Since 1969, we have performed more than concern of 91 patients during the diagnostic
100 alcohol celiac plexus nerve blocks at stage of their disease. Nine percent experi-
The Mason Clinic. This report presents per- enced no pain until some time after a tissue
tinent clinical data, warns of complications, diagnosis had been made. This pain was
and is written to encourage more widespread primarily located in the epigastrium (79%)
use of this block. or mid-back (12%) and had been present
for an average of 2.4 months before the
PATIENT DATA patients were referred for nerve block. It
The average age of patients in this series was variously described as cramping, boring,
*Staff Anesthesiologist.
?Staff Anesthesiologist.
SStaff Anesthesiologist.
$Third-Year Resident.
IlDepartment of Anesthesiology, The Mason Clinic, Seattle, Washington 98101.
Read a t the 50th Congress of the International Anesthesia Research Society, March 14-18, 1976, Phoenix,
Arizona.
Paper received: 3/22/76
Accepted for publication: 8/9/76
2 ...
ANESTHESIA ANALGESIA Current Researches VOL.56, No. 1, JAN.-FEB.,
AND 1977
TABLE 1 ANATOMY
Primary Diagnosis in 100 Patients Treated The celiac plexus is the largest of the 3
with Alcohol Celiac Plexus Nerve Block giant plexuses of the sympathetic nervous
M a l i g n a n t tumors 197) N u m b e r of cases system. The cardiac plexus innervates tho-
racic structures, the celiac plexus innervates
Pancreas 67 abdominal organs, and the hypogastric plex-
Lung 9 us supplies pelvic organs. All three contain
Esophagus 6 visceral afferent and visceral efferent sym-
Stomach 5
pathetic fibers. I n addition, they contain
parasympathetic fibers which pass through
Ovary 3 as preganglionic nerves. Although both types
Colon 2 of autonomic fibers can be found in each of
Miscellaneous* 5 these plexuses, they are primarily sympa-
thetic nervous system structures. Different
- conditions
Benign
texts have used the terms celiac plexus,
Chronic pancreatitis 3
splanchnic plexus, and solar plexus to de-
“Includes lymphoma, bile duct, liver. scribe the same nerve center. The etiology
of these terms relates to emphasis being
gnawing, aching, or like “green-apple placed on the adjacent artery (celiac), con-
cramps.” The pain was constant in char- tributing nerves (splanchnic) , or the gen-
acter, with some relief being obtained by eral shape and body location (solar). The
analgesics, narcotics, and position. A com- contributing nerve supply to the plexus is
mon finding was the tendency for patients illustrated in figure 1.
to sit or lie in the fetal position with knees
drawn up into the abdomen and the back
flexed forward. TECHNIC
The technic of celiac plexus nerve block
RESULTS has been described by Moore.’ The patient
is placed in the prone position with arms
There was good to excellent pain relief in hanging down from the side of his hospital
94 percent of the cases. Fourteen patients cart. Key features include the use of skin
had the alcohol celiac plexus block repeated markings for projection of anatomic detail,
at an interval of 5 days to 1 year because the distinctive feel of injection through a
of recurrent pain. Life duration following 12.7 to 15.24-cm, 20-gauge needle rather
alcohol block was 2.4 months, with a range than a 22-gauge needle, and the use of bony
of 2 days to 1 months. I n 10 percent of
4 landmarks in placing the needle. Diagnostic
patients, it was necessary to infuse crystal- blocks are done with 50 ml of 0.15 percent
loid or other blood-volume expanders before bupivacaine. The therapeutic block is per-
they could ambulate. Eighty-five percent formed with a similar volume of 50 percent
reported being dizzy when sitting for the ethanol. This is freshly prepared by mix-
1st time after the block. Vital-sign changes ing saline or local anesthetic with absolute
were recorded in 1 patient (table 2 ) , and ethanol from commercially available am-
are fairly typical of the response to be ex- pules.
pected after alcohol block.
One point not previously emphasized has
been the use of the aorta as a vascular land-
TABLE 2 mark in locating the celiac plexus. The
An Example of Changes in Vital Signs
in 1 Patient After Alcohol Celiac Block
Blood pressure Pulse
Pre-block (supine) 145/70 90
Pre-block (sitting 2’) 140/100 96
15 minute post-block 120/70 114
(supine)
15 minutes post-block 84/65 132
(sitting 2’)
24-hour post-block (supine) 110/70 90
24-hour post-block 100/70 10’0 FIG 1. The sympathetic nervous system contri-
(sitting 2’) bution to the celiac plexus.
Celiac Plexus Nerve Block.. . Thompson, et a1 3
pancreatic nerves in 84 percent of a group
of patients with autopsy findings of car-
cinoma of the pancreas. Various authorities
claim that abdominal pain can be conveyed
via splanchnic sympathetic, vagus, phrenic,
or lumbar somatic nerves. In any given in-
stance, depending on tumor size and metas-
tases, any or all of these nerves might be
involved.
A number of reports indicate that the
sympathetic system is the primary pain
pathway in many patients.2.7 Surgical
splanchnicectomy can be performed by di-
rect cutting of nerve fibers or by injecting
neurolytic solutions at the time of laparot-
omy. Although these would seem to be sim-
ple procedures for the surgeon, there are
other considerations. First, the modern fa-
cility to obtain tumor diagnosis by methods
such as laparoscopy and percutaneous bi-
opsy may obviate the need for surgical ex-
ploration. Even when laparotomy is done,
it is sometimes difficult to expose the celiac
plexus in the presence of certain tumor
masses. It is risky to inject neurolytic
FIG 2, Bony and vascular relationships of the drugs in the anesthetized patient if paraly-
celiac plexus. Aortic pulsations can be used to help sis from spreading solution is a concern.
locate the final position of the needle on the patient’s
left side. Furthermore, the patient is often con-
fused as to what is postoperative incisional
plexus is entwined around the aorta at the pain versus what is tumor pain. Efficacy of
level of the 12th thoracic and 1st lumbar the block is hard to evaluate. Therefore, we
vertebrae (fig 2 ) . It is possible to approach prefer to do the percutaneous celiac alcohol
the aorta on the patient’s left side and feel block on awake patients following a reason-
its transmitted pulsations up the shaft of able postoperative period for healing of the
a firmly held needle. The approach must incision. Routine postoperative medications
necessarily be cautious and utilize the depth are used during this time for pain control.
information gleaned by first locating the ver- Usually, these medications are unnecessary
tebral body. Moving the needle slowly for after 7 to 10 days and the patient is able
1 to 3 cm beyond the depth will allow the to lie prone while the block is done. By this
perceived pulsations to dictate a needle-tip time, most patients have an appreciation of
position near or in the celiac plexus. We use the persistent gnawing pain which they ex-
a bilateral injection and place the second perienced preoperatively and now continue
needle in the patient’s right side at a depth to find disturbing in the postoperative peri-
and angle corresponding to that of the ini- od. In addition, many have been made
tial left-sided insertion. aware of the final diagnosis and are amen-
able to a discussion of palliative therapy.
DISCUSSION Indications for diagnostic celiac plexus
In an earlier report on alcohol celiac plex- block prior to the therapeutic alcohol block
us block,’ we found the most common cause are the following:
of unremitting upper abdominal pain to be First, if a patient is uncertain about the
carcinoma of the pancreas. This disease has nature of the procedure or vague about his
shown a threefold increase in incidence pain, a diagnostic block affords him the
since 1910;3 and although an old medical opportunity to make a more rational deci-
axiom states that painless jaundice is the sion about having the neurolytic block.
sine qua non of pancreatic carcinoma, recent
s t ~ d i e s show that pain is the dominant
~,~ Second, the diagnostic block gives the
symptom during the course of the disease. physician a chance to evaluate the appro-
DrapiewskF found direct tumor invasion of priate needle size and position.
4 ...
ANESTHESIA ANALGESIA Current Researches VOI,.56, NO.I, JAN.-FEB.,
AND 1977
Finally, the physiologic consequences of TABLE 3
the block can be appreciated without undue Blood Alcohol Concentrations Following
concern when a temporary block is produced Celiac Plexus Block in 5 Patients*
with local anesthetic solution. This is of
special importance in patients with massive T i m e after Average blood
iniection, m i n concentration, g m / 1 0 0 rnl
ascites, obesity, hypoproteinemia, anemia,
or hypovolemia. 0 0
We have found no need to complicate the 10 0.005
performance of celiac block by using x-ray 20 0.017
or fluoroscopy to locate the needle position. 30 0.018
This has been advocated but does not serve
40 0.013
to guarantee a lack of complications or accu-
rate placement of solution. Familiarity with *:Each patient received 50 ml of 5~07~
ethyl alcohol.
the block is best achieved by using it on a
regular basis in the course of administering
surgical anesthesia. The combination of ce- there was no evidence of abnormal bleeding
liac block with bilateral intercostal block is or destruction of vascular walls. Alcohol is
ideally suited for any kind of upper abdom- readily absorbed into the blood stream fol-
inal surgery, and the physician using these lowing celiac plexus block. Blood alcohol
blocks on a daily or weekly basis is well levels rise acutely over the first 20 minutes
prepared for the occasional neurolytic block. (table 3 ) . The maximum level we measured
was 0.021 gm/100 ml. This is about one-fifth
The main concern in celiac block is to of the common legal standard for intoxica-
avoid a flat trajectory of the needle. This is tion.
most likely to occur in the obese patient who
cannot lie in a prone position. It is also Although it is difficult to define success
likely to occur when the novice is perform- when treating pain, 60 of these patients con-
ing the block. It is vitally important to draw sistently acknowledged a marked sense of
out anatomic markings on the skin surface pain relief following alcohol block. Most
and to mentally visualize the depth a t which often this was noted within minutes after
vertebral bodies can be located. performing the block but sometimes required
24 hours before new aches and pains sub-
Paralysis can follow celiac plexus nerve sided. These new sites of pain were con-
block, due to faulty needle placement and sidered to be due to alcohol transiently irri-
consequent spread of drug into the epidural tating the diaphragm or back musculature.
space, subarachnoid space, or onto the so- The pain generally subsided within a few
matic nerves a t lumbar or thoracic levels. hours, but it is good to forewarn the patient
The potential problem of permanent paraly- that such might occur.
sis from alcohol should be respected but
does not deter from the usefulness of this Good pain relief was obtained in 34 addi-
block. Our single problem in this regard was tional patients. This figure includes 14 pa-
in an obese, terminally ill woman who could tients who obtained relief after a repeat
not be turned to the proper prone position alcohol block. I n these patients a composite
because of massive ascites. A block was at- impression of pain relief was obtained by
tempted with the patient in a lateral posi- considering not only the views of the patient
tion. This compromise in technic coupled but also those of relatives, referring physi-
with the anatomic distortions of obesity re- cians, nurses, and anesthesiologists. It some-
sulted in spread of alcohol solution to nerve times happened that the family was more
roots of the lumbar plexus. She developed impressed with the results of alcohol celiac
a partial unilateral leg paralysis. block than was the patient. They observed
such things as more restful sleep, better ap-
Physicians unfamiliar with alcohol celiac petite, and less agitated motion spent in
plexus block might envision a gigantic area trying to “get comfortable” or to gain relief
of necrosis in the retroperitoneal area sur- by assuming the fetal position. It is im-
rounding the site of injection. However, our portant to include these impressions as well
repeated observations at the time of autopsy as those of the referring physician in arriv-
have revealed no grossly discernible changes. ing a t a therapeutic success figure.
Studies” in dogs have shown mild inflam-
matory changes and severe degenerative Some possible reasons prompting repeat
changes in nerves and ganglia following block are nerve regeneration, increase in size
phenol injection around the celiac axis. of primary tumor, or the growth of meta-
Despite the large blood vessels in this area, f
stases. I the initial alcohol block gave good,
Celiac Plexus Nerve Block. . . Thompson, et a1 5
albeit transient, relief, or if further diag- Th,e celiac plexus is a well-localized cen-
nostic blocks indicated potential for further ter in which pain messages from various
relief of pain, we were not at all reluctant sites in the abdomen have traffic. It is a
to do a 2nd or even 3rd neurolytic block. sacrificable nerve center without the dis-
The block was considered poor or ineffective turbing side effects of motor sensory and
in 6 people, including all 3 patients with visceral-function loss consequent to destroy-
chronic pancreatitis. ing other nerves or plexuses. The pain re-
lief obtained from alcohol celiac plexus
We have noted some variable but encour- block can complement or obviate the need
aging side benefits, in addition to pain re- for more deleterious approaches to analge-
lief, as a primary reason for doing this block. sia used in patients with carcinoma of the
Many patients note improved bowel motility upper abdomen. It is one of the simplest,
and may even pass gas or stool per rectum most effective, and least hazardous means
within minutes of celiac plexus block. This of palliative therapy. It is the single most
is due to depression of sympathetic tone to effective neurolytic nerve block. We would
the gut with relative overbalance of vagal encourage anesthesiologists to gain famili-
input. Another, but more temporally spaced, arity with celiac plexus block by doing it
explanation relates to decreased use of nar- with local anesthetic agents in routine sur-
cotics, with consequent increase in bowel gical anesthesia. This should lead to its
tone and motility. Several other patients greater application in the field of pain
have experienced less nausea and regurgi- therapy.
tation of food. Accompanying this has been
improved appetite and even weight gain. REFERENCES
The block is not advocated as a cure for all 1. Moore DC: Regional Block. Fourth edition.
problems of malignant disease, but these Springfield, Illinois, Charles C Thomas, Publisher,
effects were encouraging when observed. 1975
2. Bridenbaugh LD, Moore DC, Campbell DD:
An interesting theoretic question is wheth- Management of upper abdominal cancer pain: treat-
er neurolytic block of the celiac plexus ment with celiac plexus block with alcohol. JAMA
might result in an “unvigilant” abdomen. 190:877-880, 1964
Could certain conditions such as bowel ob- 3. Krain LS: The rising incidence of carcinoma
struction, cholecystitis, or appendicitis de- of the pancreas, real or apparent. J Surg Oncol
velop and go unrecognized? This has not 2: 115-124, 1970
happened in our experience. The same ques- 4. Lowe WC, Palmer ED: Carcinoma of the pan-
tion crossed the minds of physicians who creas: an analysis of 100 patients. Am J Gastro-
earlier treated hypertensive cardiovascular enterol 47:412-420, 1967
disease by bilateral thoracolumbar sympa- 5. Parkash OM: On the statistical and clinical
thectomy.8 Apparently, this did not prove evaluation of carcinoma of the pancreas. Digestion
to be worthy of concern, but it could be a 6: 152-164, 1972
matter to consider when alcohol celiac block 6. Drapiewski JR: Carcinoma of the pancreas: a
is contemplated for the pain of benign dis- study of neoplastic invasion of nerves and its pos-
ease like chronic pancreatitis. For this rea- sible clinical significance. Am J Clin Pathol 14:549-
son, but especially because of our poor re- 556, 1944
sults in achieving pain relief in this group, 7. Cooping J, Willix R, Kraft R: Palliative chem-
it is recommended that the block be used ical splanchnicectomy. Arch Surg 98:418-420, 1969
primarily for treatment of pain from malig- 8. Ray BS, Neil1 CL: Abdominal visceral sensa-
nant disease. tion in man. Ann Surg 126:709-724, 1947