For relief of pain from non-pelvic intra-abdominal organs.
Acute pain - may be performed during surgery for postoperative pain relief.
Chronic pain - useful for any condition that causes chronic severe upper abdominal visceral pain - e.g. chronic pancreatitis (local anaesthetic blocks only).
Cancer pain - useful for upper abdominal organ cancer pain, and is frequently used for carcinoma of the pancreas - initial diagnostic local anaesthetic block, followed by neurolytic block.
Bleeding and infection risks.
Where the source of the pain is no longer being transmitted through the autonomic nerves.
It is dangerous to perform the block in the presence of a large aortic aneurysm.
The coeliac plexus is also known as the solar plexus. It is the main junction for autonomic nerves supplying the upper abdominal organs (liver, gall bladder, spleen, stomach, pancreas, kidneys, small bowel, and 2/3 of the large bowel). The celiac plexus proper consists of the celiac ganglia with a network of interconnecting fibers. The ganglia lie on each side of L1 (aorta lying posteriorly, pancreas anteriorly and inferior vena cava laterally).
Greater splanchnic nerve (T5/6 to T9/10)
Lesser splanchnic nerve (T10/11)
Least splanchnic nerve (T11/12)
The upper abdominal organs receive their parasympathetic supply from the left and right vagal trunks, which pass through the coeliac plexus but do not connect there.
The block is performed using X-ray screening, intravenous sedation, local anaesthetic infiltration of the superficial layers, with the patient in the prone position.
Intravenous fluids are required pre-block to reduce the risk of hypotension after the procedure. It normally takes two needle insertions, one on each side to block both of the coeliac ganglia, but on some occasions good spread to both sides is achieved just using one needle. The needle entry point is just below the tip of the 12th rib, and using X-ray screening in two planes, the needle is advanced until it hits the side of the L1 vertebra.
Figure of coeliac plexus block technique
The needle is withdrawn slightly and then redirected forwards until it is in the area of the coeliac plexus, avoiding the aorta and inferior vena cava. Radio-opaque dye is injected to confirm the correct placement of the needle, and then the appropriate mixture is injected:
For non-malignant pain: 10 ml 0.5% chirocaine on each side
For malignant pain: 5 ml 6% aqueous phenol + 5 ml 0.5% chirocaine on each side
As the block causes dilatation of the upper abdominal vessels, venous pooling can occur, leading to hypotension. This can be excacerbated by pre-existing dehydration, hence the need for IV hydration before performing the block.
- Severe hypotension may result, even after unilateral block.
- Bleeding due to aorta or inferior vena cava injury by the needle.
- Intravascular injection (should be prevented by checking the needle position with radio-opaque dye).
- Upper abdominal organ puncture with abscess/cyst formation.
- Paraplegia from injecting phenol into the arteries that supply the spinal cord (prevented by checking the needle position with radio-opaque dye).
- Sexual dysfunction (injected solution spreads to the sympathetic chain bilaterally).
Intramuscular injection into the psoas muscle.
- Lumbar nerve root irritation (injected solution tracks backwards towards the lumbar plexus).