endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic...

Endoscopic Ultrasound-Guided Celiac Plexus Blockfor Managing Abdominal Pain Associated WithChronic Pancreatitis: A Prospective Single CenterExperienceFrank Gress, M.D., Colleen Schmitt, M.D., MHS, Stuart Sherman, M.D., Donato Ciaccia, M.D.,Steven Ikenberry, M.D., and Glen Lehman, M.D.Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana; andUniversity of Tennessee—Chattanooga, Chattanooga, Tennessee

OBJECTIVE: In our previous randomized trial, we suggesteda possible role for endoscopic ultrasound (EUS) guidedceliac plexus block in the treatment of abdominal painassociated with chronic pancreatitis. The purpose of thisstudy was to evaluate our prospective experience with EUS-guided celiac plexus block for controlling pain attributed tochronic pancreatitis, including follow-up on response ratesand complications.

METHODS: All subjects enrolled had documented chronicpancreatitis by ERCP and EUS criteria and presented withchronic abdominal pain unresponsive to current treatmentoptions. All were treated with EUS-guided celiac plexusblock under the guidance of linear array endosonographyusing a 22-gauge FNA needle (GIP, Mediglobe Inc., Tempe,AZ) inserted on each side of the celiac area, followed byinjection of 10 cc bupivacaine (0.25%) and 3 cc (40 mg)triamcinolone on each side of the celiac plexus. Individualpain scores, based on a visual analog scale (0–10), weredetermined preblock and postblock by a nurse at 2, 7, 14days and monthly thereafter. Subjects also rated their overallcomfort level during the EUS procedure.

RESULTS: EUS-guided celiac plexus block was performedin 90 subjects (40 males, 50 females) having a mean age of45 yr (range 17–76 yr) between July 1, 1995 and December30, 1996. A significant improvement in overall pain scoresoccurred in 55% (50/90) of patients. The mean pain scoredecreased from 8 to 2 post EUS celiac block at both 4 and8 wk follow-up (p , 0.05). In 26% of patients there waspersistent benefit beyond 12 wk, and 10% still had persistentbenefit at 24 wk, including three patients who were pain-freebetween 35 and 48 wk. Younger patients (,45 yr of age)and those having previous pancreatic surgery for chronicpancreatitis were unlikely to respond to the EUS-guidedceliac block. Three patients experienced diarrhea post EUSceliac block, which resolved in 7–10 days; however, it isunclear whether this diarrhea was due to the block or torefractory disease. A cost comparison between the EUS

($1200) and CT ($1400) techniques shows the EUS celiacblock to be less costly and perhaps more cost efficient in asubset of subjects.

CONCLUSIONS: EUS-guided celiac plexus block appears tobe safe, effective, and economical for controlling pain insome patients with chronic pancreatitis. Younger patients(,45 yr) and those having prior pancreatic surgery forchronic pancreatitis do not appear to benefit from this tech-nique. Prophylactic antibiotics should be considered if acidsuppressing agents are being taken. (Am J Gastroenterol2001;96:409–416. © 2001 by Am. Coll. of Gastroenterol-ogy)

INTRODUCTION

The chronic abdominal pain associated with chronic pan-creatitis is a challenging problem for the gastroenterologist.The management of this pain can be difficult and, at times,frustrating (1–3). Many approaches have been used to treatthese patients, including pancreatic enzymes, narcotic anal-gesia, celiac plexus block, or surgical ganglionectomy. Un-fortunately, these therapies have had a variable and limitedsuccess rate for long-term pain control. Some patients re-spond to combined multimodality therapy, but many have,unfortunately, become dependent on narcotic agents. Forthis reason, the use of narcotics to manage chronic pain hasbeen met with some resistance as well as the fear of possibledrug addiction (3–5).

Celiac plexus block plus neurolysis has been reported tobe useful in managing chronic pain. Celiac block is a tem-porizing treatment because it utilizes a long-acting localanesthetic that will eventually wear off. In contrast, neurol-ysis utilizes a more permanent agent (i.e., ethanol or phe-nol). Initially described by Kappis as a percutaneous trans-posterior technique, numerous variations of this modalityhave since been reported (6). The most important variationsinclude the use of a fluoroscopically-guided percutaneousapproach and, more recently, computed tomography-guided

THE AMERICAN JOURNAL OF GASTROENTEROLOGY Vol. 96, No. 2, 2001© 2001 by Am. Coll. of Gastroenterology ISSN 0002-9270/01/$20.00Published by Elsevier Science Inc. PII S0002-9270(00)02344-3

techniques, using transposterior and anterior approaches(7–11). Transcutaneous ultrasound has also been used toperform an anterior percutaneous celiac plexus block (12).

Celiac plexus block has been utilized for the temporaryrelief of pain in some patients. In the past, this procedure hasbeen performed by anesthesiologists and/or pain manage-ment specialists using a blind translumbar fluoroscopic ap-proach, or by the radiologist using a transposterior CTtechnique, and now, more frequently, a transanterior ap-proach under CT guidance (6–11).

Although celiac plexus block may be successful for thecontrol of pain, it is successful in only some patients withchronic pancreatitis. Furthermore, the response varies con-siderably. There have been a number of reports in theradiology literature casting doubt on a therapeutic role forCT-guided celiac block in the treatment of chronic pancre-atitis pain (13–17). The CT technique is relatively easy toperform. However, the risks include back pain (for thetransposterior approach), retroperitoneal hemorrhage, infec-tion, and paralysis. The latter can occur if ethanol is used asthe neurolytic agent. Unfortunately, there is little in the formof clinical outcomes data or prospective trials to suggest thatthe celiac plexus block actually benefits patients.

The development of endoscopic ultrasound (EUS), and,more recently, a linear array EUS instrument that allows forultrasound-guided fine needle aspiration (FNA), has in-spired innovative interventions for managing GI disease(18–25). The advent of EUS-guided FNA and the ability ofEUS to allow visualization of vascular structures using colordoppler has allowed for the development of EUS-guidedceliac plexus block/neurolysis. This technique was initiallydescribed in a small series of patients with pancreatic cancerwho reported some improvement in pain symptoms usingethanol injection (26). The technique is safe and, in expe-rienced hands, can be performed in a short time period.Because the EUS technique is performed transgastrically,there are minimal risks. This may be attributed to the factthat EUS provides improved visualization of the celiac axisand hence, more accurate placement of the anesthetic agentsused. Furthermore, this precrural approach for deposition ofthe celiac blocking agents also may lessen risk of moreserious complications like paraplegia, which is more com-mon with the translumbar/retrocrural approaches.

We recently reported on our randomized trial comparingthe efficacy of EUS-guidedversusCT-guided celiac plexusblock for controlling the abdominal pain of chronic pancre-atitis (27). We observed a significant improvement in painsymptoms with patients randomized to EUS-guided celiacplexus block. Overall, EUS-guided celiac block providedimproved pain control over a longer time period (;12 wk)than the CT-guided technique (;4 wk). We noted onecomplication—a peripancreatic abscess caused by bacterialseeding as a result of acid suppression and gastric coloni-zation. Although our sample size was small, this studysuggested that the EUS technique may benefit some chronicpancreatitis patients with intractable abdominal pain not

controlled by current treatment modalities. We postulatedthat our success with the EUS-guided celiac block for treat-ing chronic pancreatitis pain was related to the close prox-imity of the EUS instrument and FNA needle to the celiacplexus. Although our sample size was small, it suggested apossible alternative method for achieving some pain relief ina subset of patients with chronic pancreatitis who havefailed the current standard of care. The aim of this currentprospective study was to evaluate the efficacy of EUS-guided celiac plexus block for managing abdominal paindue to chronic pancreatitis and to present our experience(including response rates, factors affecting a response, andcomplications) with this new technique in a large series.

MATERIALS AND METHODS

Patient SelectionPatients with chronic pancreatitis were eligible for this studyif they presented with intractable and constant abdominalpain not controlled by current therapies. These therapiesincluded pharmacological, endoscopic, and surgical inter-ventions. All subjects had chronic pancreatitis documentedby ERCP, which was also confirmed by EUS during theceliac plexus block procedure. The diagnosis of chronicpancreatitis was based on previously reported criteria. Spe-cifically, these criteria were as follows: the Cambridge clas-sification for ERCP diagnosis and, in the case of EUS, thepresence of parenchymal inhomogeneity, echogenic foci,lobular cystic architecture, small cystic spaces, pancreaticduct irregularity, and an echogenic ductal border (28–30).

A prior remote history of a CT-guided celiac block (.6months) was not considered to be an exclusion criterion.Informed consent was obtained from each patient for theendoscopy, EUS examination, and the EUS-guided celiacplexus block procedure. Patients were informed of the studypurpose and the fact that this was a new technique. Becauseour initial pilot study was institutional review board ap-proved and our results for the EUS technique promising forchronic pancreatitis pain (with the risks minimal in twopreviously published studies), we did not seek additionalIRB approval for this open enrollment study.

All patients received initial EUS-guided celiac plexusblock at Indiana University Medical Center. All subjectswere interviewed before the procedure to obtain a baselinepain score. The score was based on a previously describedvisual analog scale, with 0 equaling no pain, 5 equalingmoderate pain, and 10 equaling worst pain ever (range0–10). Another purpose of the interview was to quantifypain medication requirements before the block procedure(31, 32). During this interview, the subjects were specifi-cally asked about the severity of pain immediately beforethe procedure, 1 day before, and 3 months before. The meanof these three values equaled the preblock pain score. Pa-tients also were asked to give the names, doses, and quan-tities of pain medication being taken. Pain scores wereobtained postceliac plexus block by telephone interview.

410 Gress et al. AJG – Vol. 96, No. 2, 2001

Follow-up was obtained by a GI research nurse at 1 daypostblock; 2, 7, and 14 days postblock; and then monthlythereafter up to 52 wk postblock or until the subject wascensored. Patients also were asked to rate their overallexperience with the celiac block procedure on postblock dayone.

If any subject in the study required another celiac plexusblock before termination of this study, they were censoredfrom the study immediately after the second celiac blockwas performed. Their data were used up to the point of thesecond block. The EUS-guided celiac plexus block wasperformed in all subjects by a single experienced en-dosonographer.

Celiac Plexus Block TechniqueEUS-guided celiac plexus block was performed under theguidance of linear array endosonography (FG32UA, PentaxPrecision Instruments Corp., Orangeburg, NY), utilizing asterile 22-gauge FNA needle system (GIP, Mediglobe Inc).The technique we used, including the location of the needleduring injection, has been described previously (26–27).Briefly, the procedure was performed as follows: the aortawas traced to the celiac trunk using linear array endosonog-raphy and confirmed by color-flow Doppler. After the he-patic artery and splenic artery were localized and the celiacregion confirmed, the FNA needle was inserted into theregion via a transgastric approach. An assistant then aspi-rated a 10 cc syringe attached to the FNA needle to confirmthat the needle was not within any of the regional bloodvessels. At this point, 10 cc of bupivacaine (0.25%), (AbbottLaboratories, Abbott Park, IL), followed by 3 cc of triam-cinolone (40 mg), (Fujisawa USA, Deerfield, IL) were in-

jected on both sides of the celiac trunk and adjacent to theaorta. This technique is not sterile because the needle isinserted across the gastric wall into the celiac space. There-fore, we recommend a prophylactic broad-spectrum antibi-otic be given in those patients in whom a potential contam-ination may exist (i.e., bacterial colonization). Figure 1depicts the celiac axis with linear array endosonography asit appears during the celiac plexus block procedure.

Recovery for the EUS-guided celiac block procedure wasidentical to a routine upper endoscopy, with the exceptionthat the patient’s vital signs were monitored more closely.Blood pressure, heart rate, respiratory rate, and temperaturewere evaluated every 15 min for 1 h and every 30 minthereafter until the patient was awake, alert, and ready to bedischarged.

Statistical AnalysisNonparametric methods were used. The pain scores pre- andpostceliac plexus block were compared using the Wilcoxonsigned rank test (33). A positive response was definedapriori as a decrease in pain score$3 points. The Kaplan-Meier method was used to compare the EUS response rateover time, until the pain score returned to the pretreatmentor baseline score (33). The median change in pain score andmedian post block pain score were compared using theWilcoxon rank sum test. Multivariate analysis using Coxregression was used to evaluate the data for possible vari-ables (i.e., age, sex, prior pancreatic surgery). A two-tailedT test was used to determine any significance. A cost com-parison was performed using a previously described costanalysis that compared individual billed charges for EUS

Figure 1. Depicts the celiac axis using linear array endosonography. This image is obtained by tracing the aorta to the celiac trunk. Usually,the superior mesenteric artery can also be seen. The celiac axis is generally considered to be at the level of the celiac plexus.

411AJG – February, 2001 EUS-Guided Celiac Plexus Block For Treating Chronic Pancreatitis Pain

and the more commonly used CT-guided celiac plexusblock techniques (27).

RESULTS

Ninety consecutive patients (40 males, 50 females) with amedian age of 45 yr (range 17–76 yr) were enrolled in thisprospective study between July 1, 1995 and December 30,1996. All patients had documented moderate to severechronic pancreatitis by ERCP and EUS criteria. The etiol-ogy for chronic pancreatitis was a congenital anomaly of thepancreatic duct in 29 subjects, ethanol abuse in 34, familialin three, cystic fibrosis in two, and presumed idiopathic in22. None of the subjects had any local complications ofpancreatitis (e.g., pseudocysts, abscess, calculi) identified asa cause for their pain. All subjects enrolled had failedprevious endoscopic therapy. The mean pre-EUS-guidedceliac block pain score was 8 (range 7–10) for this series.Overall 55% (50/90) of subjects experienced decreased painat a mean postprocedure follow-up of 8 wk (range 4–24wk). This included a reduction in pain medication require-ments noted at follow-up intervals and based upon thesubject’s verbal accounting of her/his medication usage. Allresponders reported decreased pain scores at a mean post-procedure follow-up of 8 wk (range 8–24 wk). The meanpain score (MPS) after EUS-guided celiac block decreasedfrom 8 to 2 (p , 0.05) at both 4 and 8 wk follow-up.Furthermore, a persistent benefit was experienced by 26% of

subjects at 12 wk (MPS5 3.5) and by 10% at 24 wkfollow-up. Three (4%) subjects remained pain-free longterm, with two having partial relief for up to 35 wk and theother remaining pain-free for 48 wk. For the nonrespondingsubjects, the MPS pre-EUS block was 8.5, and the post-EUSblock MPS was 7.3 (p . 0.05) at 4 wk.

The data were further analyzed by multiple regressionanalysis using Cox regression and the Kaplan-Meir methodto determine what, if any, variables (age, sex, prior pancre-atic surgery) in our patient population were significant. Wefound that patients with a prior history of pancreatic surgeryfor chronic pancreatitis (p 5 0.04) and patients (,45 yr ofagep 5 0.03) were less likely to respond to the EUS-guidedceliac block when compared to all subjects. These data aredepicted in Figures 2 and 3. There was no correlationbetween the etiology of the chronic pancreatitis and re-sponse.

Three subjects experienced adverse side effects possiblyattributable to the celiac block. Diarrhea occurred in threepatients after EUS-guided celiac block and resolved spon-taneously within 7 days post-block. All three subjects hadsevere chronic pancreatitis. We observed one complication(1% risk) during this study—in one subject, a peripancreaticabscess developed 5 days after EUS-guided block. We re-ported this complication in our initial pilot study but in-cluded the EUS patients from that study as part of ourcenter’s experience reported in this study. This abscessresolved without further incident after a 14-day course of

Figure 2. Kaplan-Meier plot comparing subjects,45 yr of age to patients.45 yr of age. A positive response was identifieda priori, asa decrease in the pain score$3 points. The older patients had a more significant response to the EUS-guided celiac block (p 5 0.04).


broad-spectrum antibiotic therapy. We noted that this pa-tient was taking omeprazole, a proton pump inhibitor, at thetime of the procedure. We therefore hypothesized that acidsuppression may have contributed to this event as a result ofbacterial colonization of the stomach followed by bacterialseeding, via the FNA needle into the sterile celiac space.

Twelve patients had the opportunity to experience boththe EUS and CT techniques for performing celiac plexusblock. Of these, 67% (8/12) preferred the EUS technique,and 33% (4/12) preferred the CT technique. The reasonsgiven for preferring the EUS block were more completesedation during the procedure and lack of back pain follow-ing the procedure (usually associated with the CT tech-nique). The reason for preferring the CT block in the re-maining four patients was lack of cramping and bloating,which they experienced after the EUS technique. The meanrecovery time was 2 h for the celiac block procedure.

Using the data from this larger series, we performed aretrospective cost comparison, using cost analysis data fromour initial pilot study, which compared individual billedcharges for both EUS and the more commonly used CT-guided celiac block techniques. This cost comparison dem-onstrates that an EUS-guided celiac block costs $1200(U.S.D.) versus$1400 (U.S.D.) for the CT-guided celiacblock. When these data are extrapolated to the above clinicalresults, the cost per patient for pain control using celiacblock is less with the EUS technique. The average EUSblock lasts an average 10 wk (range 8–12 wk)versus4 wk

(range 1–4 wk) for the CT technique (as was reportedpreviously in our earlier pilot study). Therefore, using theEUS technique might result in less blocks and, thus, lesscost in a select group of patients with chronic pancreatitiswho have failed current treatment options short of surgery.

DISCUSSION

Intractable, constant, and unremitting abdominal pain attrib-uted to chronic pancreatitis can be difficult to control. In thepast, surgical treatment has usually been the last alternativefor patients with refractory pain. However, in most cases,surgery does not provide complete pain relief (16, 17, 34,35). EUS-guided celiac plexus block has been reported tohave some success with providing pain relief in patientswith intra-abdominal malignancy (26). However, becausethese patients required a more permanent celiac plexusneurolysis in the face of their malignancy, this techniqueutilized ethanol injection, as opposed to topical anestheticsand steroids.

In an earlier pilot study, we evaluated the effectiveness ofEUS-guided celiac plexus block as a treatment for thechronic abdominal pain associated with chronic pancreatitis(27). In this randomized study, we compared EUS-guidedceliac plexus block with the currently utilized CT-guidedceliac block for managing the pain associated with chronicpancreatitis. The EUS-guided celiac plexus block provideda more substantial and prolonged pain relief than the CT

Figure 3. Kaplan-Meier plot depicting mean pain scores over time for subjects requiring pancreatic surgery compared to those not havingsurgery. A positive response was defined,a priori, as a decrease in the pain score$3 points. The end point was return to the pretreatmentbaseline. Patients requiring surgical intervention did not have improved pain relief after the EUS-guided block (p 5 0.03).


technique. We found that a majority of patients receiving theEUS technique had a more significant response to the celiacblock when compared to their CT block counterparts. Be-cause these pilot data suggested that EUS-guided celiacplexus block was a promising new intervention for control-ling the abdominal pain associated with chronic pancreatitis,we initiated this present study to further investigate ourinitial hypothesis in a larger subject population. After somepromising results from our initial randomized trial, we choseto enroll all subsequent patients to EUS-guided celiacplexus block.

We opted to utilize bupivacaine and triamcinolone, in thedoses used by our interventional radiologists. We are awarethat other dosing regimens have been described; however,there have been no comparative trials to date to support theuse of one standard dosing regimen. We have not used otherdoses in the past. Furthermore, we have been reluctant to useethanol to block the celiac plexus in patients with benigndisease (i.e., chronic pancreatitis) because previous reportsin the radiological literature have suggested a higher risk forserious complications when ethanol is used for performingceliac plexus neurolysis. Although ethanol creates a morepermanent celiac neurolysis, it has been reported to rarelycause retroperitoneal hemorrhage and neurological deficits,specifically paraplegia with the transposterior CT-guidedapproach in several radiological series (2, 9, 16, 36–38).

However, an EUS-guided block with ethanol injectionmay be an acceptable alternative in select cases, because theEUS technique is anterior and the celiac trunk can be pre-cisely localized. It may be reasonable to consider usingethanol in those patients with intractable pain who respondto a trial of bupivacaine anesthetic with steroids using theEUS-guided approach. However, in one study using CT-guided celiac plexus neurolysis with ethanol, no significantimprovement was demonstrated in a small series of patientshaving an initial response to bupivacaine (16, 17).

In our study, there were many patients who had no reliefwith the EUS-guided celiac plexus block. We attempted toidentify these subjects as a group (nonresponders) to lookfor any common characteristics. We found that patients witha prior history of pancreatic surgery for their chronic pan-creatitis and patients.45 yr of age were less likely torespond to the EUS-guided celiac block. The significance ofthis is unclear but may suggest that patients presenting withchronic pancreatitis at a young age develop more severedisease earlier than those who are diagnosed in middle age.In addition, patients requiring pancreatic surgery (e.g.,Puestow procedure) usually have severe refractory diseasethat does not respond to most therapies. Interestingly, onestudy, using a fluoroscopic approach, reported similar find-ings with respect to age and prior pancreatic surgery (39). Inour present study, there were 12 subjects who had receiveda prior CT-guided block, at least 6 months before the study.It is unclear whether this remote CT-guided block couldhave affected our findings. However, when surveyed, mostof these subjects preferred the EUS-guided block over the

CT block (27). There were no significant differences inresponders to suggest that those subjects with prior CTblocks scored better improvements in their pain scores.Ideally, a similar study designed as a large, prospective,randomized, placebo-controlled trial involving chronic pan-creatitis patients having no prior interventions would bepreferred in this difficult patient population.

Interestingly, one study reporting on the natural history ofearly and late onset idiopathic and alcoholic chronic pan-creatitis noted that, in many chronic pancreatitis patients,the abdominal pain improved spontaneously over time in56–79% of patients, depending upon the etiology and timeof onset in one’s life (40). Therefore, some would argue thataggressive intervention to control abdominal pain is rarelyindicated in these patients. However, if a specific interven-tion such as EUS-guided celiac block could provide symp-tomatic relief until the natural history of chronic pancreatitishas run its course, it may be beneficial because the patientmight be able to avoid long-term narcotic usage (with itsrisk of addiction) and provide a better quality of life, as well.These issues now need to be explored in a well-designedstudy.

We did have one complication noted in our experi-ence—an abscess occurring 5 days post-EUS-guided celiacblock. It was reported earlier in our initial pilot study butwas included in this study of our overall experience (27).This event occurred in a subject taking 20 mg daily ofomeprazole, a proton pump inhibitor. We postulate thatduring the EUS-guided celiac block, bacteria was trans-ferred from the colonized stomach into the celiac space. Theperipancreatic abscess probably developed as a result ofbacterial colonization of the stomach from acid-suppressingtherapy. This patient subsequently improved after a 14-daycourse ofi.v. antibiotic (Floxin) treatment, which was com-pleted on an outpatient basis after a hospital stay of 7 days.We therefore now recommend a prophylactic broad-spec-trum antibiotic be given before performing this procedure ifbupivacaine and steroids are used as the blocking agent. Weuse a single dose of Levaquin administered parenterally justbefore the procedure. It is unknown whether ethanol, whenused as the blocking agent, is less likely to cause this risk ofinfection because of its bactericidal properties. However, inthe one published study using ethanol as the neurolytic agentduring EUS-guided celiac block performed for managingpancreatic cancer pain, no complications were reported (26).

Although our study group was homogenous (in that allpatients had chronic pancreatitis not responding to currenttreatment modalities and had failed some type of endoscopictherapy and, in a few, also pancreatic surgery), this studydoes have some limitations. It should be recognized that thisgroup of chronic pancreatitis patients represents a fairlyselect group, in that they all failed conventional and endo-scopic therapy for refractory chronic pancreatitis. Thesecases represent what may be considered the worse in chronicpancreatitis; the efficacy of EUS-guided celiac plexus blockmay actually be better in less refractory patients. However,


this study did not evaluate this point. Furthermore, ourmethod used for scoring pain, the visual analog pain scale,is subjective and in some cases may not accurately predictresponse. Ideally, a quality of life assessment would bestmeasure the results of a therapy for chronic pancreatitis andmay help clarify whether EUS-guided celiac block actuallyimproved the patient’s symptoms (41). Unfortunately, thistype of data was not collected in our study. Furthermore, wecannot exclude the possibility that some of our subjectsmight have had a spontaneous remission of their pain un-related to the EUS-guided celiac block. We doubt this,though, as all of these patients had constant unremittingpain, rather than intermittent pain. Although narcotic usagewas tabulated, it was done subjectively during a telephonefollow-up. A formal pill count was not practical as most ofthese subjects were referred from.100 miles, making fre-quent outpatient visits impractical. Therefore, future studiesin this area should be randomized, placebo-controlled trialsinvolving subjects having no prior celiac block by anymeans, and a quality of life assessment should be performed.Such studies will hopefully be able to determine the clinicalimpact, if any, of EUS-guided celiac block for managingchronic pancreatitis pain.

Overall, the EUS-guided technique is safe and easy toperform under skilled hands with minimal side effects,complications, and discomfort. We believe that this EUStechnique for performing a celiac plexus nerve block is apotential alternative in select patients with chronic pancre-atitis who fail current therapies for managing constant andintractable abdominal pain. Although the data from thisstudy are less pronounced than those from our initial ran-domized trial, we did see some significant results in a subsetof patients. Fifty subjects (55%) were considered respondersat 8 wk follow-up. Furthermore, 26% of these patients hadpersistent pain relief at 12 wk, and 10% experienced thesame at 24 wk. Three patients had long-term relief between35 and 48 wk. Most responders were older (.45 yr of age)and, in fact, all those responding beyond 8 wk were oldersubjects. We also identified a group of patients unlikely torespond to this modality. The longer duration of pain reliefprovided by EUS-guided celiac plexus block suggests itmay be cost effective because patients would require fewerceliac block procedures when compared to other techniques.However, these blocks would still be temporary, possiblyrequiring multiple procedures in 1 yr to control a patient’spain. However, additional clinical investigations with largersample populations that evaluate cost, clinical outcomes,quality of life, and the efficacy of various agents (i.e.,ethanolvs bupivacaine and steroidsvs placebo) are neces-sary before the use of EUS-guided celiac plexus block canbe considered a cost-effective alternative for treating intrac-table abdominal pain associated with chronic pancreatitis.

Reprint requests and correspondence:Frank G. Gress, M.D.,Assistant Professor of Medicine, State University of New York atStony Brook, School of Medicine and Health Sciences Center,

Chief of Endoscopy, Division of Gastroenterology and Hepatol-ogy, Winthrop-University Hospital, 222 Station Plaza North, Suite429, Long Island, NY 11501.

Received Apr. 13, 2000; accepted Sep. 25, 2000.

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