E218 UCTN – Unusual cases and technical notes

End-organ ischemia as an unforeseen complication of endoscopic-ultrasound-guided celiac plexus neurolysis1

Fig. 1 CT scan of the abdomen on post- operative day 4 dem- onstrating extensive splenic infarction.

Fig. 3 Images taken during upper endoscopy on POD 6, revealing necrosis of the antrum of the stomach.

Fig. 2 CT scan of the abdomen on post- operative day 4 (POD 4) with extensive necrosis of the head and body of Fig. 4 Images taken during upper endoscopy the pancreas. on POD 32, revealing diffusely exudative stom- ach mucosa and ongoing ischemia. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Celiac plexus neurolysis (CPN) has been The patient is a 44-year-old man with a used to treat pancreatic cancer pain for history of chronic alcohol-related pan- decades. Endoscopic ultrasound (EUS) creatitis. He suffered from debilitating has improved the safety of CPN, and has pain for several years before being offered Fig. 5 Images taken during upper endoscopy allowed its increased use for chronic pan- CPN. The procedure was performed under on POD 61, revealing diffuse antral erythema creatitis pain relief [1]. We present a pa- direct EUS visualization with linear array and ulceration, as well as pyloric stenosis. tient who developed end-organ ischemia endosonography used to obtain sagittal following EUS-guided CPN, and believe views of the celiac trunk. Aspiration test this is the first report of this type of side was performed with no blood return, and infarction (●" Fig. 1). Abdominal CT on effect stemming from this procedure. then 20 mL 0.25% bupivacaine and 20 mL postoperative day 4 revealed pancreatic dehydrated 98% ethanol were injected. necrosis (●" Fig. 2). Esophagogastroduo- Postoperatively, the patient awoke with denoscopy on postoperative day 6 showed 1 This case was presented in poster format at the ●" American College of Physicians New Hampshire severe abdominal pain. Imaging revealed extensive gastric necrosis ( Fig. 3). The Chapter Scientific Meeting, October 2008. mild pancreatic inflammation and splenic patient continued to suffer from gastric

Ahmed HM et al. End-organ ischemia as an unforeseen complication of endoscopic-ultrasound-guided celiac plexus neurolysis… Endoscopy 2009; 41: E218 –E219 UCTN – Unusual cases and technical notes E219

ischemia (●" Fig. 4), and eventually devel- death [3]. Paraplegia, a rare but well-es- 3 Yang Z, Wang J, Zheng T et al. Importance of 2+ 2+ oped pyloric stenosis and gastric outlet tablished adverse side effect of CPN, is extracellular Ca and intracellular Ca re- lease in ethanol-induced contraction of cer- ●" obstruction ( Fig. 5). He subsequently thought to be secondary to diffusion of ebral arterial smooth muscle. Alcohol 2001; underwent subtotal gastrectomy with a the neuroablative alcohol into the arteries 24: 145– 153 Roux-en-Y gastrojejunostomy, and was supplying the spinal cord [3–5]. We pos- 4 Brown DL, Rorie DK. Altered reactivity of finally discharged 94 days following CPN. tulate that a similar mechanism of injury isolated segmental lumbar arteries of dogs following exposure to ethanol and phenol. To our knowledge, this is the first report of occurred in this case and resulted in this Pain 1995; 60: 233– 236 end-organ infarction in the distribution of heretofore unreported adverse event. 5 Johnson ME, Sill JC, Brown DL et al. The effect the celiac artery following CPN. One meta- of the neurolytic agent ethanol on cytoplas- analysis found that the most common ad- Endoscopy_UCTN_Code_CPL_1AL_2AC mic calcium in arterial smooth muscle and – verse effects of CPN are local pain, transi- endothelium. Reg Anesth 1996; 21: 6 13 ent diarrhea, and hypotension [2]. Severe H. M. Ahmed, S. E. Friedman, adverse effects are uncommon (2%) and H. F. Henriques, B. S. Berk Bibliography DOI 10.1055/s-0029-1214937 include paralysis, parasthesias, prolonged Dartmouth Hitchcock Medical Center, Endoscopy 2009; 41: E218 –E219 diarrhea, renal puncture, and pneumo- Lebanon, New Hampshire, USA © Georg Thieme Verlag KG Stuttgart · New York · thorax [2]. In this case, infarction of the ISSN 0013-726X spleen, pancreas, and gastric antrum sug- References 1 Michaels AJ, Draganov PV. Endoscopic ultra- gest that an ischemic injury occurred dur- Corresponding author ing the procedure. We postulate that dif- sonography guided celiac plexus neurolysis S. Friedman, MD and celiac plexus block in the management fusion of ethanol into the celiac artery Dartmouth Hitchcock Medical Center of pain due to pancreatic cancer and chronic Hinman Box 7500 and subsequent arterial vasospasm resul- pancreatitis. World J Gastroenterol 2007; ted in the injury pattern. Ethanol at non- 13: 3575– 3580 Lebanon, NH 03766 USA toxic concentrations has been shown to 2 Eisenberg E, Carr DB, Chalmers TC. Neurolytic [email protected] result in vasoconstriction severe enough celiac plexus block for treatment of cancer pain: a meta-analysis. Anesth Analg 1995; to cause vascular and smooth muscle cell 80: 290– 295 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Ahmed HM et al. End-organ ischemia as an unforeseen complication of endoscopic-ultrasound-guided celiac plexus neurolysis … Endoscopy 2009; 41: E218– E219