A 68-year-old man with metastatic pancreatic cancer presents to the palliative care unit with severe, constant visceral abdominal pain (8/10 severity) despite adequate dosing of extended-release morphine 120 mg daily. He has no contraindications to interventional procedures. Physical examination reveals tenderness over the epigastrium and left upper quadrant. Imaging confirms tumor infiltration of the celiac plexus. Which of the following interventions is most appropriate to provide rapid, targeted pain relief in this patient?

Explanation

## Clinical Scenario: Cancer Pain with Celiac Plexus Involvement **Key Point:** This patient has opioid-refractory visceral cancer pain due to celiac plexus infiltration. Celiac plexus neurolysis is the gold-standard interventional approach for rapid, durable pain relief in this setting. ### Celiac Plexus Neurolysis: Indications and Efficacy **High-Yield:** Celiac plexus neurolysis is indicated for: - Visceral upper abdominal pain from pancreatic, gastric, or hepatic malignancy - Pain refractory to optimized systemic opioid therapy - Patients with adequate performance status for a minimally invasive procedure ### Technique Comparison | Approach | Route | Advantage | Disadvantage | |---|---|---|---| | **EUS-guided neurolysis** | Endoscopic ultrasound | Direct visualization, high accuracy, rapid onset (24–48 hrs), low morbidity | Requires endoscopy expertise; not universally available | | **CT-guided percutaneous** | Percutaneous needle | Widely available, real-time imaging | Slightly higher morbidity; delayed onset (3–7 days) | | **Fluoroscopy-guided** | Retrocrural approach | Traditional, reproducible | Operator-dependent; higher risk of vascular injury | **Clinical Pearl:** EUS-guided celiac plexus neurolysis achieves pain relief in 80–90% of patients with pancreatic cancer pain, with onset within 24–48 hours. Duration of benefit is typically 4–12 weeks, after which repeat procedures can be performed if needed. ### Mechanism of Pain Relief Celiac plexus neurolysis involves injection of alcohol (95–100%) or phenol into or around the celiac plexus, causing chemical destruction of visceral afferent fibers. This interrupts pain transmission from upper abdominal viscera without affecting somatic sensation or motor function. **Mnemonic: VISCERAL pain pathway** — Visceral afferents → Splanchnic nerves → Celiac plexus → Dorsal root ganglia → Spinal cord. Neurolysis blocks this at the plexus level. ### Why Systemic Escalation Alone Is Inadequate This patient is already on a high-dose opioid (120 mg morphine daily). Further escalation risks: - Dose-limiting side effects (sedation, constipation, respiratory depression) - Incomplete analgesia for visceral pain (opioid-refractory component) - Prolonged symptom burden while titrating Interventional neurolysis provides rapid, targeted relief without additional systemic drug burden. **Warning:** Celiac plexus neurolysis carries small risks of temporary diarrhea (due to loss of sympathetic tone), orthostatic hypotension, and rare vascular injury. However, these are outweighed by the benefit in end-stage cancer pain.