Ischemic Injury Following EUS Guided Celiac Plexus Neurolysis

Abstract

Case Presentation: A 51 yo M with metastatic pancreatic adenocarcinoma with vascular invasion presents with abdominal pain. The patient had an ERCP with CBD stent exchange and EUS with celiac plexus neurolysis (CPN). During the EUS CPN, a total of 10 cc of .25% bupivicaine and 10 cc of dehydrated Etoh were injected. One day following the procedure he had melena and subsequent coffee ground emesis with a 4 gram drop in hemoglobin from admission. An EGD showed extensive ulceration and inflammation along the lesser curvature, which was suggestive of ischemic injury. Discussion: Treatment of pain in pancreatic cancer is an important objective in palliative care. Approximately 80-85% of patients have pain associated with advanced pancreatic cancer. Options for pain control include pharmacotherapy as well as CPN, which can be performed percutaneously, surgically or under the guidance of EUS. EUS CPN has been shown to be effective in achieving pain control. In one meta-analysis of 119 patients, pain was alleviated in 73% of patients. CPN is overall felt to be safe but practitioners should be aware of the possible complications. Side effects include local pain, unopposed parasympathetic activity, which can result in diarrhea (44%) and hypotension (38%). Serious complications include retroperitoneal hemorrhage and peripancreatic abscess. In a series of 189 EUS guided celiac plexus blocks and 31 CPNs, the following 4 complications were reported: hypotension, retroperitoneal abscess, and 2 with post-procedural pain. One case report notes ischemic complications following CPN, including gastric ischemia/necrosis, splenic infarction, and pancreatic necrosis in the distribution of the celiac artery. Similarly, our patient likely developed ischemic injury following CPN. Ethanol can cause vasospasm and severe cases of vasoconstriction can lead to vascular and smooth muscle cell death. Conclusion: CPN is an effective modality for treatment of pain in advanced pancreatic cancer. However, physicians should also be aware of the complications. Patients who develop signs of GI bleeding after CPN should be evaluated for ischemic injury.Figure: No Caption available.