Celiac Block Research Articles

ID: 330272 Splanchnic nerve block: a safe and effective alternative to celiac block for median arcuate ligament-syndrome

ID: 330272 Splanchnic nerve block: a safe and effective alternative to celiac block for median arcuate ligament-syndrome

Impact of Ethno-racial Factors on Clinical Outcomes and Health Care Utilization in Chronic Pancreatitis.

Healthcare disparities adversely affect clinical outcomes in racial and ethnic minorities. Chronic pancreatitis (CP) is a complex disorder, and pressures for time and cost-containment may amplify the disparity for minorities in this condition. This study aimed to assess ethno-racial differences in the clinical outcomes of CP patients cared for at our institution. This is a study of CP patients with available ethno-racial information followed at our pancreas center. We reviewed their demographics, comorbidities, clinical outcomes, and resource utilization: pain, frequent flares (≥ 2/year), local complications, psychosocial variables, exocrine, and endocrine insufficiency, imaging, endoscopic procedures, and surgeries. The outcomes underwent logistic regression to ascertain association(s) with covariates and were expressed as odds ratio (95% confidence intervals). Of the 445 CP patients, there were 23 Hispanics, 330 Non-Hispanic Whites, 47 Non-Hispanic Blacks, 16 Asian Americans, and 29 patients from Other/mixed races. Over a median follow-up of 7years, no significant differences in the pain profile (p = 0.36), neuromodulator use (p = 0.94), and opioid use for intermittent (p = 0.34) and daily pain (p = 0.80) were observed. Frequent flares were associated with Hispanic ethnicity [2.98(1.20-7.36); p = 0.02], despite adjustment for smoking [2.21(1.11-4.41); p = 0.02)] and alcohol [1.88(1.06-3.35); p = 0.03]. Local complications (pseudocysts, mesenteric thrombosis, and biliary obstruction), exocrine and endocrine dysfunction, and healthcare resource utilization (cross-sectional imaging, endoscopic procedures, celiac blocks, or surgeries) were comparable across all ethno-racial groups. Although no significant differences in clinical outcomes, and health resource utilization were noted across ethno-racial groups, Hispanic ethnicity had significant association with CP flares. This study calls for further investigation of an understudied minority population with CP.

Role of interventional radiology in upper abdominal cancer pain management

BackgroundThe major indication for celiac plexus block is abdominal pain that is nonresponsive to analgesic interventions; often these patients are nonresponsive to high-dose opioid therapies. One of the most common indications for the celiac plexus block is the treatment of abdominal pain associated with pancreatic cancer.Aim of the workThe differences between two techniques (ultrasound and fluoroscopy guided) are highlighted in terms of effectiveness by means of a Visual Analog Scale (VAS), a percentage reduction in daily morphine consumption and any complications are recorded and evaluated at the time of implementation of each technique from start to finish.ResultsThrough the data that have been recorded and statistically analyzed, we found that the mean values of VAS were decreased in the two groups, and there was statistically significant difference between ultrasound and fluoroscopy groups.ConclusionsIt is noticeable and good in conducting this research that there are no major complications that include a large space on the study sample, despite the presence of some minor with no significant differences between ultrasound and fluoroscopy groups. This effective celiac block, regardless of the technique used, produced immediate analgesics that permitted significant opioid decrease in the study sample with a significant improvement in the unwanted adverse effects on account of opioids.

Natural History, Clinical Characteristics, and Outcomes in Idiopathic Chronic Pancreatitis.

Chronic pancreatitis (CP) is a fibroinflammatory syndrome of the pancreas associated with pain and poor quality of life. It has toxic and genetic risk factors but can also be idiopathic. The natural history of idiopathic CP (ICP) is not well-known. Therefore, we studied clinical characteristics and outcomes of these patients followed in our Pancreas Center. Review of CP patients between January 1, 2016, and April 30, 2021. Patients were divided into 2 groups based on diagnosis, ICP vs non-ICP. CP patients with a smoking history were placed in the non-ICP group. Statistical analysis was performed to identify differences in demographics, comorbidities, complications, controlled medications, and resource utilization. Out of 450 patients, 101 (22%) were diagnosed with ICP and 349 (78%) were non-ICP. ICP patients were mainly female (59.4% vs 40.5%; P= .005), had less comorbid anxiety (10.5% vs 22.1%; P= .002), depression (24.2% vs 35.8%; P < .001), disability (13% vs 16.3%; P= .021), exocrine pancreatic insufficiency (45.3% vs 62.6%; P= .004), splanchnic vein thrombosis (1.04% vs 14.9%; P < .001), pseudocysts (16.7% vs 41.6%; P < .001), and biliary obstruction (3.12% vs 19.2%; P < .001). They underwent less abdominal imaging (2.63 vs 3.42; P= .048) and endoscopic retrograde cholangiopancreatography (0.88 vs 1.32; P= .030). They also had less opioid use (29.6% vs 54.4%; P < .001), gabapentinoid use (34% vs 52.3%; P= .002), and celiac blocks (7.22% vs 16.1%; P < .041). Our study demonstrates that the clinical course of ICP is less morbid compared to non-ICP. This study specifically removes smoking, a significant risk factor for CP, to study a truly idiopathic cohort.

Radiation Exposure Reduction of CT Fluoroscopy in Targeting Celiac Plexus for Neurolysis in Chronic Pain Management

Abstract Background: Conventional CT (Computed Tomography) guided celiac block is the most accurate method for celiac block guidance the lack of real time visualization, radiation exposure & time consuming call the need for real time CT fluoroscopy guidance which provide adequate real time needle localization and radiation exposure reduction to patient and medical staff. Aim of Study: Describe technical ways that the IR (Inter-vention Radiology) team can implement ALARA (As Low As Reasonably Achievable) concept focusing on patient, operator and staff, to reduce the amount of radiation used to conduct the procedure. Patients and Methods: This study was carried out on 30 adult patients suffering from chronic abdominal pain related to infiltrative or metastatic pancreatic cancer or HCC and pain not controlled by WHO analgesic step ladder. Guided with CT fluoroscopy Celiac plexus neurolysis is performed, maximum filling of the retro-pancreatic space with ethanol is an indication of sufficient neurolysis. Applying parameters to reduce radiation exposure dose in pre-procedure helical scanning as well as get use of safety parameters of CT fluoroscopy, the total radiation dose exposure was calculated from the patient dose report. Results: The technique was successfully performed in 30 patients (100%). The mean value of total CT radiation beam intensity used to perform the procedures DLP per celiac plexus was 46.2 mGy X cm. Conclusion: CT fluoroscopy guided celiac plexus block is an easy and safe method that affords excessive success rates, applying ALARA parameters during the CTF procedure markedly decrease the affected person radiation dose in contrast with use of conventional CT guidance.

Safety and Efficacy of CT Fluoroscopy in Celiac Plexus Neurolysis in Hepatocellular Carcinoma Related Abdominal Pain

Abstract Background: Management of hepatocellular carcinoma related abdominal pain is a complex and challenging issue as most HCC develop on top of liver cirrhosis and the deficient hepatic function obstacle the high-dose narcotic analgesics. Imaging-guided Celiac plexus neurolysis for refractory pain management has been used for almost 100 years in patients with advanced abdominal malignancy and effectively control pain without the noted side effects typical of opioids, however CT guided celiac block is the most accurate method for celiac block guidance the lack of real time visualization, radiation exposure & time consuming call the need for real time CT fluoroscopy guidance. Aim of Study: To assess the efficacy of CT fluoroscopy in celiac plexus neurolysis in hepatocellular carcinoma related abdominal pain. Patient and Methods: This study was carried out on 30 adult patients suffering from abdominal pain due to infiltrative or metastatic HCC and pain not controlled by WHO analgesic step ladder. Celiac Plexus Neurolysis (CPN) is achieved with intravenous conscious sedation, prognostic block accomplished by using injecting a near by anesthetic accompanied with the aid of alcohol for celiac plexus block, after 10 minutes, if the injection correctly relieved pain; maximum filling of the retro-pancreatic area with ethanol is a sign of enough neurolysis. Results: Marked decrease of pain severity in all patients was noted as a sharp fall of the Numerical Rating Scale (NRS) score on the 1 st day post CPN with relatively stationary course for 3 months in the patient survived their primary disease. Conclusion: Celiac Plexus Neurolysis (CPN) provides an effective technique in decreasing pain severity in HCC patients, and so decreases the analgesic requirement, their side effects and may increase patients' survival, CT fluoroscopy guided CPN is an easy and safe procedure that provides high success rates, markedly decreased patient radiation dose and total procedure time compared with use of conventional CT guid-ance.

Temporary Celiac Ganglion Block as a Test Before Celiac Ganglion Resection for Dysautonomia-Related Bowel Dysmotility

Temporary Celiac Ganglion Block as a Test Before Celiac Ganglion Resection for Dysautonomia-Related Bowel Dysmotility

Celiac plexus radiosurgery for pain management in advanced cancer patients: An international phase II trial.

TPS466 Background: Many cancer patients, especially those with pancreatic cancer, suffer from severe back/epigastric pain. Contemporary approaches (opioids, celiac blocks, systemic chemotherapy) are often inadequate. This clinical trial investigates a new approach in which high-dose radiation (radiosurgery) is focused on the retroperitoneal celiac plexus nerve bundle. Preliminary results from a single institution pilot trial NCT02356406 are promising: pain relief is substantial and side effects minimal. The main aim of the trial is to establish safety/efficacy in the setting of an international multicenter study. Exploratory analyses will examine the relationship between pain reduction and subjects’ quality-of-life, functionality, and caregiver burden. Methods: Eligibility criteria include a diagnosis of metastatic/unresectable malignancy, uncontrolled pain defined as ≥ 5 on 11-point BPI-SF scale despite analgesic use, typical retroperitoneal pain syndrome, prognosis &gt; 8 weeks, ECOG 0-2, anatomical involvement of the celiac plexus (e.g. any pancreatic cancer, or any other cancer involving the celiac trunk). Exclusion criteria include previous upper abdo. radiation. The intervention consists of a single 25 Gy radiation fraction delivered to the celiac plexus, using anterolateral aspect of the aorta from the 12th thoracic to 2nd lumbar vertebral body as a surrogate structure. The primary tumour may be irradiated at physicians’ discretion. Dose-painting technique limits dose to organs at risk. Pain intensity will be measured using Brief Pain Inventory Short Form (BPI-SF), and quality of life with FACT-Hep. The primary endpoint is complete or partial pain response, defined as a decrease between the score immediately before treatment and 3 weeks’ post-treatment. A change of two or more on the BPI 11-point pain scale is defined as clinically significant. Secondary endpoints include other BPI pain endpoints, pain at 6 weeks, analgesic use, toxicity (CTCAE v4.03), quality of life and functional measures. Analgesia is not restricted. Expected accrual is 100 subjects over three years. Supported by Gateway for Cancer Research, additional support from Israel Cancer Association. Clinical trial information: NCT03323489.

Splanchnic block at T11 provides a longer relief than celiac plexus block from nonmalignant, chronic abdominal pain.

Neural blockade at the celiac plexus is less specific compared with splanchnic nerve block. This retrospective study compares duration and potency of celiac versus splanchnic block.Patients & methods: Analyzed were data of 16 consecutive patients with visceral abdominal nonmalignant pain treated using both celiac plexus and T11 splanchnic block. Improvement in pain scores was from 7.24±1.0 to 4.1±2.1 for celiac, and 7.8±0.8 to 2.9±2.1 for splanchnic at 4weeks. Duration of the splanchnic nerve block was superior, median of 56days versus only 21days for celiac plexus block.Conclusion: T11 bilateral splanchnic block provided significantly longer relief from chronic nonmalignant abdominal pain, than celiac plexus block (p=0.001). Reduction in pain severity was more with splanchnic compared with celiac block (p=0.029).

Celiac Plexus Radiosurgery, a New Modality for Cancer Pain Management – Final Results of a Phase II Clinical Trial

Many patients with upper-abdominal malignancies suffer from a characteristic syndrome of severe lower back pain radiating to the epigastrium, thought to be caused by involvement of the celiac plexus. Contemporary approaches (opioids, celiac blocks, systemic chemotherapy) are often inadequate. We hypothesized that ablative radiation delivered to the celiac plexus would alleviate pain levels. We performed a single-institution prospective clinical trial to evaluate a novel therapeutic approach: stereotactic radiation therapy focused on the celiac plexus. Eligibility criteria included typical celiac-pain syndrome, significant pain despite opioid usage (Numerical Rating Scale, NRS > 4/10), prognosis > 8 weeks, ECOG 0-3. Evaluable patients were defined as those completing treatment per protocol and completed at least one post-treatment visit. Exclusion criteria included previous abdominal RT. The anterolateral aspect of the aorta from D12 to L2 was used as a surrogate marker for the celiac plexus; primary tumor was irradiated according to physicians’ discretion. Radiation dose was originally 9 Gy*5, and later amended to a single fraction 25 Gy, both using VMAT. A dose-painting technique was used to limit dose to duodenum. The primary endpoint was pain-relief 3 weeks post-treatment, measured using NRS. Secondary endpoints included pain at 6 weeks, analgesic use, toxicity (CTCAE v4.03), and pain interference with seven daily activities as evaluated by the ‘Brief Pain Inventory' (BPI) instrument before and after radiation therapy. Analgesic use was not restricted. Twenty-one subjects were evaluable: 2 received 9Gy*5, 19 received 25Gy*1. The median age was 65 (range 37-83 years) with a Median ECOG of 1, 86% had pancreatic cancer. Median volume of celiac plexus was 30.8 cc, median dose to celiac plexus was 25 Gy. All patients reported decreased celiac pain: median pain level prior to RT was 6/10 (IQR 5-7.5) and reduced to 2.3/10 NRS score (IQR 0.9-3.3) (p <0.0005 compared to baseline) at 3 weeks (primary endpoint), and to 1.8/10 (IQR 0-3) (p <0.0005 compared to baseline) at 6 weeks’ post-treatment. 76% of patients reported a significant decrease of pain at primary endpoint (two point decrease), and in one third of patients the celiac pain had been eliminated entirely during follow-up. Toxicity was minimal and limited to grade 1-2 (2 patients reported mild worsening of pain immediately following treatment, some limited nausea/vomiting). Median daily morphine equivalent dose consumption decreased (NS). A significant improvement was noted in all evaluated measures of quality of life. Celiac plexus radiosurgery is well tolerated, substantially decreases pain, and improves quality of life amongst patients with advanced upper-GI cancer. An international multicenter phase II trial is currently accruing.

3:27 PM Abstract No. 402 Partial splenic artery embolization in 35 cancer patients

Thrombocytopenia in cancer patients often contraindicates chemotherapy and/or surgery leading to suboptimal therapy and decreased overall survival. The purpose of our study was to determine safety and efficacy of partial splenic embolization to improve platelet count and to establish a standardized treatment plan to achieve ideal embolization endpoint and minimize postprocedural complications. Medical records of 35 cancer patients who underwent 39 splenic artery embolizations with 300-500 μm Embospheres were analyzed. The target embolization endpoint was 50-70% splenic infarct. Celiac plexus block was performed following 25 procedures for pain control. The spleen volumes were 1337 ± 1038 mL. The embolization led to 59 ± 16% splenic infarct. One mL of microspheres resulted in 272 ± 107 mL splenic infarct in patients with chemotherapy- or portal hypertension-induced splenomegaly and 582 ± 3 45 mL infarct in patients with hematologic malignancies. The spleen volumes decreased by 40.5 ± 11% in 1 year. The platelet count increased from 63.9 ± 29.6 (mean ± SD) to peak platelet count of 248 ± 118 in 2-4 weeks after embolization. Patients with follow-up period of >1 year had the last platelet count of 174 ± 113 (n = 12). The most common complication was moderate/severe pain which occurred in 92% of patients without celiac block and in 20% of patients with celiac block. There was non-occlusive portal vein thrombus in 2 patients, pulmonary embolus in 1 patient, focal pancreatitis in 1 patient, and increased ascites and pleural effusion in 7 patients. Procedure-related 30–day mortality was 25% amongst patients with hematologic malignancies and 0% amongst patients with chemotherapy- or portal hypertension-induced splenomegaly. Partial splenic embolization is effective to correct thrombocytopenia in cancer patients and provides improved platelet count for long-term. It is a low risk procedure in patients with chemotherapy- or portal hypertension-induced splenomegaly, but has high mortality in hematologic malignancies. The postprocedural pain was significantly reduced by celiac plexus block. Based on our data the required amount of beads can be calculated to achieve target splenic infarct.

How I Do It: Celiac and Splanchnic Plexus Neurolysis

Celiac block to alleviate pain in the upper abdomen was first described by Kappis in 1914. Since then the role of this procedure has been fairly established in the management of pain related to pancreatic disease and also in pain related to liver, gall bladder and gastric diseases. This article discusses the clinical indications and technical details of celiac and splanchnic neurolysis.

Celiac block in paediatric patients using endoscopic ultrasound for management of severe pain due to chronic pancreatitis. Review of the technique in 2 cases

Abstract Background Pancreatic diseases such as cancer, idiopathic recurrent pancreatitis, and chronic pancreatitis, can cause pain that is difficult to control. Pain is one of the most debilitating symptoms and demands increasing doses of analgesics and narcotics, as well as the number of hospital admissions, with a direct implication in the costs of medical treatments. Objective To describe the experience with 2 paediatric patients who were subjected to an ultrasound-guided endoscopic celiac ganglion block for difficult pain management, secondary to chronic pancreatitis disease. Clinical cases The first case concerns a 9-year-old male with a diagnosis of chronic pancreatitis, and the second case is a 12-year-old female who developed episodes of intermittent acute pancreatitis. Both cases suffered from chronic abdominal pain, which was difficult to control with stronger painkillers, such as opioids. The pain decreased after patients were subjected to an ultrasound-guided endoscopic celiac ganglion block. Conclusions This technique showed that both patients obtained satisfactory pain relief, with significant improvements in general symptomatology and the stopping of almost all analgesic medication. The authors suggest that celiac ganglion block must be considered, and implemented early before the usual complications, such as a consumption syndrome that is frequent in paediatric patients with chronic pancreatitis.

P-219 Celiac ganglion block for abdominal cancer pain, CT guided approach

P-219 Celiac ganglion block for abdominal cancer pain, CT guided approach

Comparative Study of the Effects of the Retrocrural Celiac Plexus Block Versus Splanchnic Nerve Block, C-arm Guided, for Upper Gastrointestinal Tract Tumors on Pain Relief and the Quality of Life at a Six-month Follow Up.

BackgroundThe celiac plexus and splanchnic nerves are targets for neurolytic blocks for pain relief from pain caused by upper gastrointestinal tumors. Therefore, we investigated the analgesic effect of a celiac plexus block versus a splanchnic nerve block and the effects of these blocks on the quality of life six months post-intervention for patients with upper GIT tumors.MethodsSeventy-nine patients with inoperable upper GIT tumors and with severe uncontrolled visceral pain were randomized into two groups. These were Group I, for whom a celiac plexus block was used with a bilateral needle retrocrural technique, and Group II, for whom a splanchnic nerve block with a bilateral needle technique was used. The visual analogue scale for pain (0 to 100), the quality of life via the QLQ-C30 questionnaire, and survival rates were assessed.ResultsPain scores were comparable in both groups in the first week after the block. Significantly more patients retained good analgesia with tramadol in the splanchnic group from 16 weeks onwards (P = 0.005, 0.001, 0.005, 0.001, 0.01). Social and cognitive scales improved significantly from the second week onwards in the splanchnic group. Survival of both groups was comparable.ConclusionsThe results of this study demonstrate that the efficacy of the splanchnic nerve block technique appears to be clinically comparable to a celiac block. All statistically significant differences are of little clinical value.

Comparative Study Between 2 Protocols for Management of Severe Pain in Patients With Unresectable Pancreatic Cancer

The efficacy of a celiac plexus block for the treatment of upper abdominal cancer-related pain has been documented. However, the effect of preprocedural pharmacological control of pain on its efficacy remains unknown. The researchers investigated the effect of first controlling severe pain with medications and then performing the celiac plexus block and compared the results with those obtained when the celiac block was performed first followed by pharmacotherapy for controlling severe pain; the impact on and duration of pain relief, effect on the quality of life, and analgesic requirements were analyzed. Sixty patients with nonresectable pancreatic cancer reporting visual analog scale (VAS) ≥ 70 (visceral pain, continuous or intermittent) were randomized into 2 equal groups. Group I comprised patients in whom the celiac block was performed early after the first meeting and then analgesic requirements were managed according to the severity of pain and the World Health Organization analgesic ladder. Group II comprised patients in whom analgesics were first given to control pain and the celiac plexus block was performed only when the patients reported a VAS score < 40. VAS and total daily analgesic consumption were recorded before the block, followed by weekly for 1 month, monthly for 6 months, and finally in the 9th and 12th months. Patient satisfaction was assessed using a quality of life questionnaire (QLQ-C30). Patients were asked to report any side effects particularly related to the procedure and intake of opioids. Pain scores were comparable in both groups at initial assessment. However, in group II, VAS was reduced to 29.2 ± 4.48 in 8 ± 3 days through medical treatment before performing the block. At all time periods examined, pain scores were significantly lower in both groups compared with pretreatment scores (P < 0.0001). There was a significant decrease in VAS in group II when compared with group I at 2 months after the procedure and thereafter (P < 0.0001). Morphine sulfate consumption and frequency of opioid adverse effects were significantly lower in group II from the second month onward (P < 0.0001). The number of patients who showed good response to tramadol was significantly higher in group II in the second month until the 6th month (P < 0.05). QLQ-C30 was significantly lower in group II compared with group I from the 2nd month onward (P < 0.0001). Controlling severe pain with medication and then performing the celiac block seems to be more effective in controlling pain, reducing opioid consumption, and improving the quality of life of patients with pancreatic cancer compared with performing the celiac block at the beginning followed by pharmacotherapy for pain relief.

An Intriguing Case of Gastrointestinal Bleeding

Case Report: A 32-year-old woman with a history of a fatty abdominal tumor resected in childhood was referred to us for melena and anemia. She had a history of duodenal ulcer in 2007 while on NSAIDs for back pain. Subsequently developed gastric perforation and underwent surgical repair with a Graham patch. She continued to have melena and anemia requiring transfusions every 1-2 months. She remained on PPI and denied the use of NSAIDs. Between 2007 and 2008 she underwent several endoscopic procedures that revealed gastric ulcers. She underwent a partial gastrectomy, truncal vagotomy, Roux-en-Y gastrojejunostomy with celiac block in 2008 due to recurrent overt bleeding. However she still continued to bleed and required blood transfusions every 1-2 months. Gastrin, secretin stimulation and basal acid output were normal. Repeat enteroscopy with wide variety of hemostasis techniques failed to control bleeding that was seen primarily within the proximal Roux limb and at the site of the jejunojejunostomy. Small bowel biopsies showed increased intraepithelial lymphocytes and villous blunting. She was tried on a gluten free diet for possible celiac disease with no resolution of symptoms. She developed severe malnutrition and protein losing enteropathy. Between 2007 and 2011 she had been seen at several other institutions by several different providers. Intraoperative endoscopy in July 2011 showed normal jejunojejunostomy but significant inflammation, ulceration and punctuate bleeding within the roux limb and giant gastric body ulcer. Total gastrectomy with Roux-en-Y esophago-jejunostomy and feeding jejunostomy was performed. Resected specimens showed nonspecific inflammatory changes but this was not consistent with either sprue or refractory sprue, ischemia, vasculitis, autoimmune enteropathy, or IBD. She continued to be symptomatic. We were convinced that she had an autoimmune process causing recurrent ulcerations and started her on prednisone with no benefit. Remicaide was started in October 2011. She was sent to another institution where in addition to repeating all the above procedures she tested positive for NSAIDs and aspirin. When confronted, the patient admitted that she had been using NSAIDs, although she had repeatedly always denied it. It was clear then that the patient had been using NSAIDs all along and her recurrent ulcers were from surreptitious NSAID use. She is currently awaiting psychiatric evaluation. Conclusion: Factitious disorders are underdiagnosed because hospital personnel often fail to spot the deceptions that are characteristic of this disorder. Although she was evaluated at several institutions by multiple providers, this diagnosis was not entertained.

Evaluation of Trans-Aortic Oblique Fluoroscopic Tunnel Vision Approach of Celiac Plexus Block after Failure of the Classic Approach

The conventional techniques of neurolytic celiac plexus block (NCBP) sometimes cannot be used in patients who have organomegaly, or not be able to tolerate the prone position necessary to place the needles; also anatomic anomalies may hinder obliquely placed needles from effectively reaching the target area. Complications such as organ puncture cannot be avoided with conventional techniques. The purpose of this study was to evaluate the safety and efficacy of a single needle transaortic celiac plexus block under an oblique tunnel view fluoroscopic guidance approach of celiac plexus alcohol block. Fifty patients with advanced upper abdominal cancer in whom the classic celiac plexus block failed were included in the study. A percutaneous single needle transaortic celiac plexus block under an oblique tunnel view fluoroscopic guidance was done at the level of middle L1 vertebra). Visual analog score, daily morphine consumption, duration of the procedure, adverse effects, and Quality of Life Questionnaire-QLQ-C30 were recorded. The mean visual analog score, daily morphine consumption significantly decreased and Quality of Life Questionnaire-C30 score significantly improved after the procedure. Conclusion: The percutaneous single needle transaortic celiac plexus block under an oblique tunnel view fluoroscopic guidance approach for celiac plexus block for upper abdominal cancer pain is proved to be safe and reliable and can be used as an alternative to the classic approach.

The Effect of Celiac Plexus Block in Critically Ill Patients Intolerant of Enteral Nutrition

In this study, we evaluated the efficacy of celiac plexus block for the treatment of feeding intolerance in critically ill patients. Nineteen mechanically ventilated medical patients intolerant of enteral nutrition and receiving metoclopramide underwent bilateral celiac plexus block. The anterior procedure was accomplished under sonographic guidance with the injection of either 25 mL bupivacaine 0.25% (celiac group, n = 10) or saline (control group, n = 9) bilaterally. Gastric emptying was assessed by the acetaminophen absorption method. After the block, nasogastric feeding was commenced, and nasogastric aspirates were collected once every 24 hours. Successful feeding was defined as 24-hourly gastric residual volume <250 mL with a feeding rate > or = 40 mL/h. Demographic data were similar for the 2 groups. The area under the plasma paracetamol absorption curve (383.8 +/- 248.1 mg . min . L(-1)) and the peak plasma paracetamol concentration (C(max); 3.28 +/- 2.15 mg/L) in the celiac group were significantly lower than the area under the curve value (1233.5 +/- 771.2) and C(max) value (10.14 +/- 6.04) in controls (P < 0.001 for all). After treatment, celiac plexus block reduced the mean gastric residual volume (celiac group: 430 +/- 32 mL to 205 +/- 30 mL, P < 0.001; control group: 450 +/- 33 mL to 461 +/- 19 mL, P > 0.05) and improved the proportion of patients with successful feeding (celiac block 80% vs controls 0%, P < 0.001). In critical illness, celiac plexus block is effective for treating feeding intolerance when IV drug therapy has failed to improve gastrointestinal dysfunction.

Endoscopic ultrasound in chronic pancreatitis: Where are we now?

Endoscopic ultrasonography (EUS) is well suited for assessment of the pancreas due to its high resolution and the proximity of the transducer to the pancreas, avoiding air in the gut. Evaluation of chronic pancreatitis (CP) was an early target for EUS, initially just for diagnosis but later for therapeutic purposes. The diagnosis of CP is still accomplished using the standard scoring based on nine criteria, all considered to be of equal value. For diagnosis of any CP, at least three or four criteria must be fulfilled, but for diagnosis of severe CP at least six criteria are necessary. The Rosemont classification, more restrictive, aims to standardize the criteria and assigns different values to different features, but requires further validation. EUS-fine needle aspiration (EUS-FNA) is less advisable for diagnosis of diffuse CP due to its potential side effects. Elastography and contrast-enhanced EUS are orientation in differentiating a focal pancreatic mass in a parenchyma with features of CP, but they cannot replace EUS-FNA. The usefulness of EUS-guided celiac block for painful CP is still being debated with regard to the best technique and the indications. EUS-guided drainage of pseudocysts is preferred in non-bulging pseudocysts or in the presence of portal hypertension. EUS-guided drainage of the main pancreatic duct should be reserved for cases in which endoscopic retrograde cholangiopancreatography has failed owing to difficult cannulation of the papilla or difficult endotherapy. It should be performed only by highly skilled endoscopists, due to the high rate of complications.