Pain

Pain in the upper abdomen or mid-back may be caused by the tumor involving or invading nerves or organs that lie near the pancreas. Pain can also be caused if the tumor causes a blockage in the digestive tract. Treatment, including pain medications and procedures such as a celiac plexus nerve-block (see below), can be important in managing pancreatic cancer pain. Since most pain medications lead to constipation which can make the pain much worse, a doctor can prescribe medications to avoid constipation.

What is a celiac plexus block?
A celiac plexus block is a procedure that damages the celiac nerves with the intent to ease pain. It is sometimes used to treat abdominal pain in pancreatic cancer. The celiac plexus block procedure damages these nerves for 3-6 months until they repair themselves.

Why use a celiac plexus block?
Patients with advanced pancreatic cancer often experience severe abdominal pain. They often require strong pain medications, such as opioids, to manage this pain. However, pain medications can cause uncomfortable side effects, such as constipation. A celiac plexus block may be considered if:

• pain medication produces unmanageable side effects, or
• pain is uncontrollable with pain medication.

Often, patients with advanced pancreatic cancer experience breakthrough pain. Breakthrough pain is an intense period of pain experienced even when medication to control more constant pain is in use. Medications are available to treat breakthrough pain, but this method of treatment is not always effective. A celiac plexus block can help a patient avoid breakthrough pain, but generally does not eliminate all pain. A celiac plexus block may reduce the need to use pain medications and may alleviate many of the unwanted side effects that may accompany opioid use.

The block may not help patients whose pain is not radiating from the bundle of nerves in the upper abdomen. A doctor or nurse would help make this determination.

What happens during a celiac plexus block and who performs the procedure?
A celiac plexus block can be performed during surgery, during an endoscopic ultrasound (EUS) or by going through the skin, called a percutaneous approach. In all cases, a doctor will first inject a painkiller (anesthetic) to numb the celiac nerves followed by a substance to damage the nerves. The effects of the anesthetic are almost instantaneous, but are not long-lasting. The nerve killing, or neurolytic, substance is usually an alcohol or a steroid and may take up to one week to be fully effective. In many cases, a few minutes pass between the two injections. Sometimes, the doctor will perform a trial block with the anesthetic medication 8-72 hours prior to the actual block using the neurolytic substance.

Surgical Approach
If a patient is able to undergo surgery for pancreatic cancer, the pancreatic or gastrointestinal surgeon will operate with the intent to remove the pancreatic tumor. If, after opening the abdomen, the surgeon determines that the tumor is cannot be surgically removed, a nerve block may be performed to help manage pain that may be caused by the tumor.

EUS Approach
Endoscopic ultrasound (EUS) is a procedure used to image the digestive tract, including the pancreas. An endoscope is passed through the patient’s mouth into the stomach and the top part of the small intestine. Then, ultrasound is used to create images of the pancreas. Just before an EUS, the patient will receive sedative medication through a vein in the arm and local anesthetic spray to the throat, in order to be comfortable during the procedure. Since sedative medications are used, the patient should prepare in advance to have someone else drive him/her home after the procedure.

A patient may have an EUS specifically so the doctor can perform a celiac plexus block or the patient may already be scheduled for an EUS for other reasons. A patient who is scheduled to have an EUS procedure and who experiences uncontrolled pain should discuss the celiac plexus block option with the gastroenterologist prior to the procedure.

Percutaneous Approach
During a percutaneous celiac plexus block, the celiac nerves are accessed by inserting a needle through the skin. In this case, an anesthesiologist who specializes in pain management typically inserts the needle through the back.

First, an IV is inserted into the arm to provide the patient with pain relief and hydration throughout the procedure. Then, the patient lies face down on an x-ray table. An area of the patient’s back is cleansed and numbed with a local anesthetic. A dye is injected and an x-ray or computed tomography (CT) scan image helps the doctor guide the needle to the correct location. Then, the anesthetic is injected into the celiac nerve bundle followed by the neurolytic substance.

How long does the celiac plexus block procedure take?
The celiac plexus block itself takes 30-60 minutes. However, the actual time required depends on which method is used to access the celiac nerve bundle.

What happens when the celiac plexus block is finished?
When the celiac plexus block is completed, the celiac nerves are unable to send pain messages to the brain. Most patients feel some, though not total, relief from pain after the procedure. Since the nerve block typically lasts 6-9 months, the procedure may need to be repeated.

What are the possible side effects?

Complications related to a celiac plexus block can be serious and severe. A celiac plexus block is not recommended for patients taking blood-thinning medication or who have an infection or bowel obstruction. Talk at length with your healthcare team about the benefits and risks of a celiac plexus block to determine if it is the right procedure to manage your pain.

• Low blood pressure (hypotension) along with a feeling of warmth in the legs immediately following the procedure
• Diarrhea
• Pain in the area of the injection (tenderness, swelling, bruising)
• Muscle spasm at the area of injection

Less Common Side Effects:

• Delayed gastric emptying and diarrhea if the anesthetic or neurolytic substances spread and affect the nerves that assist in bowel function
• Damage to kidneys
• Paralysis if the fluid used to destroy the celiac nerve spreads into the spinal or epidural space
• Accidental injection into the blood vessels causing a seizure or reduced blood supply to the spinal cord
• Seizure caused by accidental injection into the blood vessels
• Allergic reaction to the dye or medications injected
• Accidental puncture of an organ
• Infection (increased redness or swelling) at the injection or IV site

Cancer Pain Resources

Pain.com

Cancer-Pain.org
Association of Cancer Online Resources

Partners Against Pain

The information and services provided by the Pancreatic Cancer Action Network, Inc. are for informational purposes only. The information and services are not intended to be substitutes for professional medical advice, diagnosis or treatment. If you are ill, or suspect that you are ill, see a doctor immediately! The Pancreatic Cancer Action Network does not recommend nor endorse any specific physicians, products or treatments even though they may be mentioned on this site. In addition, please note that any personal information you provide to the Pancreatic Cancer Action Network's associates during telephone and/or email consultations may be stored in a secure database to assist the Pancreatic Cancer Action Network, Inc. in providing you with the best service possible. Portions of the constituent data stored in this database may be used to inform future programs and services of the Pancreatic Cancer Action Network, Inc., and may be provided in aggregate form to third parties to guide future pancreatic cancer research and treatment efforts. The Pancreatic Cancer Action Network, Inc. will not provide personal identifying information (such as your name or contact information) to third parties without your advanced written consent. 111230