Celiac plexus neurolysis (CPN) has been used to treat pancreatic
cancer pain for decades. Endoscopic ultrasound (EUS) has improved the safety of
CPN, and has allowed its increased use for chronic pancreatitis pain relief
[1]. We present a patient who developed end-organ
ischemia following EUS-guided CPN, and believe this is the first report of this
type of side effect stemming from this procedure.
The patient is a 44-year-old man with a history of chronic
alcohol-related pancreatitis. He suffered from debilitating pain for several
years before being offered CPN. The procedure was performed under direct EUS
visualization with linear array endosonography used to obtain sagittal views of
the celiac trunk. Aspiration test was performed with no blood return, and then
20 mL 0.25 % bupivacaine and 20 mL dehydrated
98 % ethanol were injected. Postoperatively, the patient awoke
with severe abdominal pain. Imaging revealed mild pancreatic inflammation and
splenic infarction ([Fig. 1]). Abdominal CT on
postoperative day 4 revealed pancreatic necrosis ([Fig. 2]). Esophagogastroduodenoscopy on postoperative
day 6 showed extensive gastric necrosis ([Fig. 3]). The patient continued to suffer from
gastric ischemia ([Fig. 4]), and eventually
developed pyloric stenosis and gastric outlet obstruction ([Fig. 5]). He subsequently underwent subtotal
gastrectomy with a Roux-en-Y gastrojejunostomy, and was finally discharged 94
days following CPN.
Fig. 1 CT scan of the abdomen
on post-operative day 4 demonstrating extensive splenic infarction.
Fig. 2 CT scan of the abdomen
on postoperative day 4 (POD 4) with extensive necrosis of the head and body of
the pancreas.
Fig. 3 Images taken during
upper endoscopy on POD 6, revealing necrosis of the antrum of the stomach.
Fig. 4 Images taken during
upper endoscopy on POD 32, revealing diffusely exudative stomach mucosa and
ongoing ischemia.
Fig. 5 Images taken during
upper endoscopy on POD 61, revealing diffuse antral erythema and ulceration, as
well as pyloric stenosis.
To our knowledge, this is the first report of end-organ infarction
in the distribution of the celiac artery following CPN. One meta-analysis found
that the most common adverse effects of CPN are local pain, transient diarrhea,
and hypotension [2]. Severe adverse effects are uncommon
(2 %) and include paralysis, parasthesias, prolonged diarrhea,
renal puncture, and pneumothorax [2]. In this case,
infarction of the spleen, pancreas, and gastric antrum suggest that an ischemic
injury occurred during the procedure. We postulate that diffusion of ethanol
into the celiac artery and subsequent arterial vasospasm resulted in the injury
pattern. Ethanol at nontoxic concentrations has been shown to result in
vasoconstriction severe enough to cause vascular and smooth muscle cell death
[3]. Paraplegia, a rare but well-established adverse side
effect of CPN, is thought to be secondary to diffusion of the neuroablative
alcohol into the arteries supplying the spinal cord [3]
[4]
[5]. We
postulate that a similar mechanism of injury occurred in this case and resulted
in this heretofore unreported adverse event.
Endoscopy_UCTN_Code_CPL_1AL_2AC
