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Pain and regional anaesthesia · Core08 / 13

Pancreatic cancer pain: neurolytic coeliac plexus block58-year-old man, 62 kg, with inoperable cancer of the pancreatic head and epigastric pain boring through to his back

Cancer pain: neurolytic coeliac plexus block, consent and complications

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Know this first

  • The coeliac plexus supplies all abdominal viscera except the left colon and pelvis.
  • Neurolysis: 50–100% alcohol or 3–12% phenol; a local anaesthetic block first can predict efficacy.
  • Common effects: back pain, diarrhoea, orthostatic hypotension. Rare: paraplegia, retroperitoneal haematoma.
  • The WHO ladder is now used both ways, with procedures brought in earlier.

The patient

58-year-old man, 62 kg, with inoperable cancer of the pancreatic head and epigastric pain boring through to his back. Oral modified-release morphine 120 mg/day plus breakthrough doses; constipated, drowsy, sleeping poorly. Referred for CT-guided neurolytic coeliac plexus block. Vitals: BP 112/70, HR 92, SpO2 97% on air, RR 16; platelets 180 × 10⁹/L, INR 1.1.

The examiner asks

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  1. Consider

    What are your considerations?

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    • A 58-year-old with inoperable pancreatic cancer, visceral pain and troublesome opioid side effects. Patient
    • His pain isn't only physical: depression and anxiety are common in cancer and make pain worse.
    • Pancreatic pain runs through the coeliac plexus, which supplies most of his abdominal organs. Disease

  2. Prepare

    How do you optimise his drug treatment?

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    • The WHO ladder now runs both ways; we can skip rungs and bring procedures in early. Disease
    • Rotating his opioid can restore analgesia with fewer side effects; methadone is a common choice.
    • Laxatives for his constipation; adjuvants such as gabapentinoids if neuropathic features appear.
    • The palliative care team stays involved throughout. After surgery

  3. Plan

    How is the block done, and how do you consent him?

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    • Neurolytic coeliac block is very effective for pancreatic cancer pain and guidelines back it. Disease
    • Image-guided: CT, fluoroscopy or ultrasound, with contrast to check the spread. Surgery
    • A local anaesthetic test block first can predict whether neurolysis will work.
    • Neurolysis with 50–100% alcohol or 3–12% phenol.
    • Consent: back pain, diarrhoea and postural hypotension are common; paraplegia is rare but serious. Patient
    • IV fluid before the block, because the sympathetic block will drop his preload. Disease

  4. Crisis

    Twenty minutes after neurolysis he feels faint. BP 74/40, HR 104, SpO2 96%. What do you do?

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    • Hypotension from the splanchnic sympathetic block is most likely; I get help. Crisis
    • Lie him flat, give oxygen, and run IV fluid fast.
    • Phenylephrine 50–100 mcg or ephedrine boluses to hold his pressure.
    • Exclude bleeding: retroperitoneal haematoma or aortic injury; Hb now and a scan if it persists.
    • I check his leg power: new weakness means spinal cord injury and urgent imaging.
    • Fluid replacement for diarrhoea over the next days; an intrathecal pump if the block fails. After surgery

Fatal mistakes

  • Neurolysis without imaging guidance.
  • No IV fluid before the block.
  • Ignoring new leg weakness after the procedure.
  • Escalating his morphine indefinitely without offering the block.

Checked against: Barash 9e · Faust · Mayo review

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