Celiac Ganglion Block: Endoscopic and Transabdominal Approaches

Paul E. Bigeleisen

Background and indications: Block of the celiac ganglion is usually used for the diagnosis of visceral pain syndromes or the treatment of pain from visceral malignancies.

The traditional approach to celiac ganglion block used a bilateral posterior approach in which the needle was placed anterior to the aorta using a transcrural approach. This was done either blind or with fluoroscopy. Subsequently, practitioners used a transaortic approach, again with a blind, fluoroscopic, or computed tomography (CT)-guided technique. Other practitioners have used a transabdominal approach using fluoroscopy, CT, or ultrasound guidance.

The advent of endoscopic ultrasound has made the celiac block and neurolysis simple and very safe. An endoscopic ultrasound probe consists of two imaging modalities placed into one probe. The first part of the probe is a flexible endoscope, which is identical to any flexible endoscope used for upper gastroenterological procedures. The second part of the probe is an ultrasound imaging device, which functions in the same way as a transesophageal echocardiogram (see Fig. 46.2) Thus, the practitioner must be familiar with the basics of gastrointestinal endoscopy as well as transesophageal echocardiography in order to employ the technique. Many university gastroenterology departments have endoscopic ultrasound machines, but the technology has not diffused into the private community at this time.

Anatomy: The celiac ganglion is predominantly a sympathetic plexus with afferent pain fibers from the foregut. Foregut organs from the distal esophagus to the splenic flexure are innervated by afferents traveling through the celiac ganglion (Fig. 46.1). Efferent fibers from the vagus also traverse the ganglion. The ganglion surrounds the celiac artery and spreads over the anterior surface of the aorta at the level of the 12th thoracic vertebra and the first lumbar vertebra.