Overview of Celiac Plexus Block
The celiac plexus block (CPB) is a medical procedure that has been in use for about a hundred years. It was initially introduced to aid in surgeries involving the upper abdomen by numbing the area. The CPB focuses on a complex network of nerves located in your abdomen, often referred to as the solar plexus. This network plays a crucial role in controlling various organs like the liver, gallbladder, stomach, pancreas, spleen, kidneys, and part of the intestines.
Primarily, the CPB is used to block pain signals coming from these organs, making it an important tool for diagnosing and managing pain within the abdomen. It’s usually brought into action when pain cannot be managed with less intense pain relief methods. The CPB is mostly used to alleviate pain due to cancerous growths and other similar conditions affecting the abdominal organs. Among these conditions, pancreatic cancer is the most common one which necessitates the use of CPB. However, the use of CPB to treat chronic pancreatitis, a long-term inflammation of the pancreas, is still being debated among the medical community.
Anatomy and Physiology of Celiac Plexus Block
The celiac plexus, also known as the solar plexus, is a complex network of nerves that helps control many of your body’s internal organs in the abdomen such as the liver, gallbladder, stomach, pancreas, spleen, kidneys, and parts of the intestines. This network of nerves is the most extensive part of our autonomic nervous system, which controls functions in our body automatically and thus plays a crucial role in keeping these organs working properly.
Location-wise, the celiac plexus is located near the celiac and superior mesenteric arteries in the region of the T12 and L1 vertebrae. It is situated in front of the parts of the diaphragm that anchor it (diaphragmatic crura) and behind the stomach. This network of nerves has a mesh-like structure and is made up of several key parts:
- Celiac ganglia: These are the main parts of the celiac plexus and include clusters of nerve cell bodies on the left and right side. These act as primary relay stations, meaning that they help transmit signals between the internal organs and the rest of the body.
- Superior mesenteric ganglion: This is found near the superior mesenteric artery. It is connected to the celiac plexus and helps control the middle part of the gut.
- Inferior mesenteric ganglion: This is found near the inferior mesenteric artery. It is also connected to the celiac plexus and helps control the lower part of the gut.
Additionally, there are several smaller parts of the celiac plexus that connect to the main parts and collectively contribute to this intricate network of nerves.
The celiac plexus includes sensory nerves (afferent) and motor nerves (efferent). The motor nerves are mainly made up of sympathetic nerve fibers which originate from the T5 to T12 level of the spinal cord, then go to the celiac ganglia. From there, these nerves spread out and connect to the internal organs in the abdomen. Parasympathetic nerves also form part of the celiac plexus, mostly coming from the vagus nerve (cranial nerve X).
Sensory nerves in the celiac plexus help transmit signals of pain and other sensory information from the internal organs to the brain. These nerves follow the same pathways as the motor nerves, sending signals back to the spinal cord and then to the brain.
This complex nerve network plays a central role in controlling functions in various organs. These include actions in the digestive system, like controlling the release of digestive enzymes, moving food through the intestines, and controlling blood flow to these organs. It also regulates blood flow in the abdomen by managing the constriction and dilation of blood vessels.
Another important function of the celiac plexus is transmitting sensations of pain from the abdomen to the brain. Because of this, it often becomes a target for treatments like nerve blocking or nerve destruction (neurolysis) in conditions that involve ongoing abdominal pain or cancers. These treatments aim to reduce severe discomfort and improve quality of life.
Why do People Need Celiac Plexus Block
Celiac Plexus Block (CPB) is a method that doctors use to help control severe abdominal pain, especially when other less intensive pain-relief methods, like medications, aren’t working. In certain cases, patients might need to rely on powerful pain medicines, like opioids, for relief. CPB can help reduce this dependence.
The CPB procedure focuses on specific nerve fibers that carry pain signals from various parts of your abdomen, including organs like the liver, gallbladder, stomach, and parts of the intestine. It helps ease pain linked to both cancerous and noncancerous conditions affecting different parts of the abdomen.
One of the common uses of CPB is to help control pain related to pancreatic cancer. It’s important to know that there are ongoing discussions among doctors about using CPB for long-term pancreas inflammation that causes pain.
Depending on the condition causing the pain, doctors may use different medications during the CPB procedure. For noncancerous conditions, they usually use local anesthetics and steroids. But for cancer-related pain, a modified form of CPB, called neurolytic celiac plexus block, is often used.
Pancreatic cancer is the second most common stomach-related cancer in the United States and can cause significant pain. Often normal pain medicines are not enough to control this pain. CPB, especially when done with neurolysis (a procedure that destroys nerve tissue), can be a game changer. It not only helps relieve the pain but can also reduce the usage of strong pain medications like opioids, leading to greater patient satisfaction.
In conclusion, CPB is a very useful medical procedure for managing chronic abdominal pain, especially for conditions affecting the abdominal organs, such as pancreatic cancer. By directly targeting the nerve fibers carrying the pain signals in the abdomen, CPB significantly alleviates severe pain and enhances the quality of life for patients suffering from chronic pain.
When a Person Should Avoid Celiac Plexus Block
When doctors decide to use a method called CPB (which stands for cardiopulmonary bypass), they must carefully consider a patient’s overall health and any existing medical conditions. Some people may have other illnesses or health problems that could affect how safe this procedure is for them.
If a patient’s health isn’t in the best shape, things can be more complicated. This includes people who are undergoing treatments like chemotherapy or radiation for cancer. These treatments can weaken the immune system, so doctors have to consider the patient’s higher risk of getting an infection after the procedure.
There can also be concerns about blood problems. Sometimes people have conditions, like coagulopathies or thrombocytopenia, where their blood doesn’t clot well or they have a low platelet count, and this can make serious bleeding complications more likely.
Even with the help of high-tech scans, such as computed tomography (CT) or fluoroscopy, there’s always a chance that the blood vessels or nearby body parts could accidentally get damaged during the procedure. For patients with cancer, the doctors especially need to keep in mind that there might be hidden tumors spread throughout the body.
So, making this decision is not taken lightly. Doctors will thoroughly examine all the possible risks, taking into consideration patient’s consent, the state of their blood clotting, possible infections, and body structure. This is all done to ensure the right decision is made whether or not this treatment should be used.
Equipment used for Celiac Plexus Block
New developments in medical imaging techniques have made a procedure called Celiac Plexus Block (CPB) safer and more effective. The CPB is a type of pain management technique often used for pain in the abdomen. This procedure was found to be effective and safe in a comprehensive review and study. Using a CT scan (a type of X-ray that takes detailed pictures of the body) or fluoroscopic guidance (a type of imaging technique that uses X-rays to obtain real-time moving images of the body’s interior) can decrease the risk of complications. However, there is still a chance of injury to blood vessels or the nearby body tissues.
For this procedure, the following will be needed:
- A C-arm: This is a medical imaging device that is based on X-ray technology and used for real-time imaging during surgeries.
- Lead apron and thyroid shield: These are protective clothing to prevent direct exposure to radiation.
- An Operating Room (OR) table that allows a C-arm to fit underneath it.
- Step stool: This could be necessary for some patients, particularly those with chronic pain and restricted movement, to climb onto the OR table.
- A pointer that can be seen in the scout fluoroscopic images to mark the starting point of the procedure.
- A single drape with a hole in it to keep the area sterile during the procedure.
- A prep solution to clean and sterilize the surgery area.
- 5 mL 1% lidocaine: This is a local anesthetic that numbs a specific area of the body to help reduce pain or discomfort during the procedure.
- A 25 g x 1.5” hypodermic needle: This is a hollow needle used to inject the local anesthetic beneath the skin.
- 3 mL of contrast substance in a 3 mL syringe: The contrast substance helps to enhance the medical imaging and allows a physician to see a clear picture of the area.
- 22 g x 7” quincke needles: These are the main needles that will be used for this procedure.
- 10 mL 0.25% bupivacaine in a 10 mL syringe: This is another local anesthetic that will be injected to numb the area during the procedure.
Who is needed to perform Celiac Plexus Block?
A cervical plexus block is a procedure that needs to be conducted by certain specialist medical staff. This includes a highly trained doctor who knows how to perform the block, which is a type of treatment where medication is injected around the nerves in your neck to reduce pain or to work as an anesthesia during surgical procedures.
Also, there can be a surgical assistant or a tech depending on what the doctor thinks is best. Their job is to support the doctor by helping with things like handling instruments or preparing the area for the block.
Another important member is the radiology technician who manages the C-arm. The C-arm is a special type of X-ray machine that helps the doctor see exactly where to give the injection.
Finally, there is a circulating nurse who looks after the patient. This could involve tasks like watching your vital signs (your heart rate, blood pressure, breathing rate, and body temperature) to make sure everything is normal during the procedure.
How is Celiac Plexus Block performed
A celiac plexus block (CPB) is a medical procedure used to alleviate severe abdominal pain. It begins by injecting local anesthesia to numb the area, which also helps confirm if the procedure will alleviate the pain. Alcohol is commonly used in CPB to optimize pain relief, based on its proven effectiveness in various studies.
There are predominantly two methods of CPB, known as the posterior and anterior para-aortic techniques. Additionally, a technique called cryoneurolysis, and another directed by endoscopic ultrasound guidance, might also be considered for the procedure.
The CPB procedure relies on different types of medical imaging such as CT scans or fluoroscopy, which work like live X-rays, to identify the right area for treatment. Some studies suggest that guidance through endoscopic ultrasound might provide better pain relief, last longer and lower the overall cost of the procedure.
1. Posterior Para-Aortic Approach:
In this method, the patient lies on their stomach with appropriate abdomen support. Notable bodily landmarks are noted, including the midline spine, buttock crests, 12th rib, and the edges of the back muscles. The area is then cleaned and prepared according to standard medical procedures.
By using CT or fluoroscopy, the T12 and L1 vertebrae are identified along with the lower border of the 12th rib. Anesthesia is then administered at this location. A special needle is inserted at about a 45-degree angle. The needle moves from the posterior (backside) towards the anterior (front side), from the T12 to the L1 vertebrae, until it touches the vertebral body.
The needle is pushed a little further into a layer called the prevertebral fascial plane. The placement of the needle is then ascertained through imaging techniques. Once the needle is correctly positioned, either a therapeutic or diagnostic block is performed.
While a block on either side, especially on the left, is often sufficient, there may be cases where a bilateral approach (on both sides) is necessary.
2. Anterior Para-Aortic Approach:
In this procedure, the patient lies on their back. The path for the needle is determined using CT or fluoroscopy. The procedure then follows the standard cleaning and preparation protocols. Anesthesia is given into the abdominal wall, preceding the T12 vertebra. A needle is then inserted towards the aorta. The needle usually passes through the bowel, the stomach, and the liver. The final needle location is in front of the aorta and diaphragm. The agent responsible for blocking the nerves for pain, or neurolytic agent, is then introduced to the area in front of the muscle of the diaphragm.
This method is generally easier, quicker, and better-tolerated than the previous approach. It’s particularly appropriate when patients have either an advanced illness, stomach discomfort, can’t lie on their stomach, or have recently had abdominal surgery. It carries a risk of accidental injury to organs; hence, care and precision are important during this approach.
Possible Complications of Celiac Plexus Block
Even though they’re rare, complications can sometimes happen from CPB (Celiac Plexus Block), a medical procedure used to manage pain. One of the most common complications is orthostatic hypotension, or low blood pressure when you stand up. This can usually be managed by staying properly hydrated. Other less common risks exist too, and these can happen even when doctors use imaging tools to guide them. Here are a few potential issues:
- Mistakenly injecting the numbing medicine into a blood vessel
- Damaging the tissues near the celiac nerve, which include nerve roots, blood vessels, muscles, and nearby organs
- Development of unusual sensations like numbness or tingling, also known as paresthesia
- Accidental injection of the numbing medication into the spinal cord
- Bleeding, sometimes causing a pool of blood to collect in the back of the body (retroperitoneal hematoma)
- Pneumothorax, which is a collapsed lung
- Infection, occasionally leading to an abscess, which is a pocket of pus
- Paraplegia, or loss of function in the lower half of the body
- Negative reactions to the local anesthetic, potentially affecting the brain and heart
Another possible side effect is diarrhea, which can sometimes happen after CPB. This happens because the procedure disturbs the balance of nerves that control the digestive system, causing an increase in its activity.
What Else Should I Know About Celiac Plexus Block?
Pancreatic cancer is one of the most common types of cancer affecting the abdomen in the United States. People with this kind of cancer often suffer from severe pain that can’t be fully managed with medications alone. Using a treatment method known as ‘CPB with neurolysis’, which involves a method to relieve nerve pain, doctors have seen success in reducing pain. This treatment also helps in decreasing the use of strong pain relief medications called opioids and in improving the patient’s overall comfort and satisfaction.