Abdominal pain secondary to metastaic pancreatic cancer

[painfre]

Pt with stage IV Pancreatic cancer presenting with severe abdominal pain radiating to back on Fentanyl 400mcg/hr, 60 MG MS contin Q 12 hr , Morphine IR 90 q 3hrs . Pt alert and not much relief. Tried Celiac plexus block(retrocrural L1 two needle) Pain relief lasted for one day.
Any recommendations. Repeat block, ? Phenol Block? Any one has experience of SCS trial for few weeks. Life xpectancy 3-6 months pre onco.


Some of the CT fidings as below

Abdomen: A 2.3 x 2.4 cm mass at the pancreatic body/head junction
is significantly increased in size. There is no pancreatic ductal dilatation or atrophy. This mass abuts the right lateral aspect of the proximal SMV.

New extensive abdominal lymphadenopathy is seen, with examples as follows: Along the gastrohepatic ligament measuring 10 mm , celiac axis lymphadenopathy such as measuring 10 mm, periaortic retroperitoneal lymphadenopathy such as measuring , as well as numerous new peripancreatic and small bowel mesentery lymph nodes such as measuring 12 mm

A new small filling defect at the portal splenic confluence likely represents a small area of partially occlusive portal venous thrombus.

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[Ducttape]

phenol neurolysis....

IT pump...

 

[Doctodd]

Lots of neurontin....besides that, anything the patient wants.

 

[melancholy]

if pt alert, consider med adjuvants in addition to either repeat block or neurolysis as mentioned above. med adjuvants could include ATC acetaminophen, NSAID, neuropathic agents, and even consideration for adjuvant Methadone (with EKG clearance, but allowance into grey area of QTc).

If Morphine helped previously but built tolerance, may have to rotate. Plus don't like morphine for pancreatic dz. If pt can't say that Morphine was ever helpful in the past, then may want to rotate it anyway.

 

[nvrsumr]

One day of relief with celiac block begs for neurolysis.

 

[kstarm]

Is the patient inpatient or outpatient?

Agree with neurontin or lyrica. Consider adding a tricyclic as well. I've seen two patients with pancreatic cancer that did better after repeat celiac plexus block. In both cases GI had done celiac blocks via Endoscopy, and then we did retrocrural approach. If inpatient you could consider IV ketamine. The opioids are at high doses, is there more generalized pain like OIH-if so he might actually feel better if by coming down on the dose. You could consider converting some to methadone for some of the NMDA effect. IT pump could be considered but I have less experience with them....

 

[lobelsteve]

With that amount of narc on board, nothing will help from a PO standpoint.

COnvert to fentanyl patch, slap on a 100mcg. Start Actiq or Fentora.

Send to IR for phenol or alcohol neurolysis with CT guidance.

If all fails then IT pump.

No role for SCS with 3-6 month to go.

 

[mille125]

Pt with stage IV Pancreatic cancer presenting with severe abdominal pain radiating to back on Fentanyl 400mcg/hr, 60 MG MS contin Q 12 hr , Morphine IR 90 q 3hrs . Pt alert and not much relief. Tried Celiac plexus block(retrocrural L1 two needle) Pain relief lasted for one day.
Any recommendations. Repeat block, ? Phenol Block? Any one has experience of SCS trial for few weeks. Life xpectancy 3-6 months pre onco.


Some of the CT fidings as below

Abdomen: A 2.3 x 2.4 cm mass at the pancreatic body/head junction
is significantly increased in size. There is no pancreatic ductal dilatation or atrophy. This mass abuts the right lateral aspect of the proximal SMV.

New extensive abdominal lymphadenopathy is seen, with examples as follows: Along the gastrohepatic ligament measuring 10 mm , celiac axis lymphadenopathy such as measuring 10 mm, periaortic retroperitoneal lymphadenopathy such as measuring , as well as numerous new peripancreatic and small bowel mesentery lymph nodes such as measuring 12 mm

A new small filling defect at the portal splenic confluence likely represents a small area of partially occlusive portal venous thrombus.

Agree with no more po
Fentora
Neurolysis
IT pump

NO Stim

 

[NEA]

Tunneled titanium epidural catheter with Dilaudid and bupivacaine going through portable pump. Now hospices have started to accept these and is a game changer for end of life care. It will get infected in about 3-6 months but so is the life expectancy.

 

[ultm8frisbee]

Gotta go with neurolytic block. I go trans-aortic on the left, 10ml of 100%EtOh. on the right side a little anterior to the L1 vertebral body and another 5-10ml of 100%EtoH there. Frequent spot checks on lateral checking that your contrast is not going posterior. Really don't have to worry about that on the left side when your in front of the aorta. I used to do them under CT, but it blows a lot of time in my day. I will review CT to ensure that going in with flouro landmarks will get me in the right area. Check axial cuts and look for take off of celiac artery off of aorta. If they don't get relief with this after 3-5 days, go directly to ITP without trial. These patient's do so well with pumps, if they have a decent life expectancy (3months) don't waste their time on a some prolonged trial.

 

[Ducttape]

Tunneled titanium epidural catheter with Dilaudid and bupivacaine going through portable pump. Now hospices have started to accept these and is a game changer for end of life care. It will get infected in about 3-6 months but so is the life expectancy.

if over 3 months, a pump would be better, and less limiting in terms of a patient's activity level...

 

[drf]

I don't bother with diagnostic celiacs in these. I always do splanchnic neurolytics as I don't have to worry about intraabdominal disease preventing spread of neurolytic.

I start at L1, orbit and tilt so I end up with bilateral needles at anterior aspect of mid portion of T12. 10-15 ml bupivacaine 0.5% each needle. I wait 5-10 minutes. If pt tells me pain is 30-50 % better I do a lower extremity motor exam then inject equal volume 100% etoh, flush needles and pull out. I've probably done 50 in the last 1-2 years and have yet to have a cancer patient tell me the pain is not better. If they did I would not inject the etoh.

If mets are outside visceral innervation I either tunnel an IT cath or place a pump based on life expectancy. Some of my hospices will take tunneled catheters.

Finally, if celiac is not sufficient and I am unable to place IT meds for administrative reasons IV lidocaine, IV ketamine, and Dilaudid PCA with basal works great. Almost all hospices will take IV infusions.

I once had a metastatic colony cancer pt on IT Dilaudid 3.8 mg/hr on service. I came on and the plan at that point was pump then discharge. Hospice would not take infusions. I realized he would need a refill every couple of days so this was not really reasonable. He was just as awake and with great analgesia on lido 1 mg/kg/hr and ketamine 25 mg/hr. Dilaudid PCA with a 2 mg basal and 2 mg bolus I think. This was a couple of years ago but I was still impressed with how happy he and his family were.

 

[painfre]

Pt is still seeking outpatient management. Pt is already on about 3600 mg of Neurontin.
Is Dehydrated 100 % Etoh Preferred over phenol for celiac plexus block ?

 

[lobelsteve]

Pt is still seeking outpatient management. Pt is already on about 3600 mg of Neurontin.
Is Dehydrated 100 % Etoh Preferred over phenol for celiac plexus block ?

As long as you are using the CT scanner, either is fine.

 

[epidural man]

phenol neurolysis....

Or ETOH >50%.

It may improve mortality.

http://onlinelibrary.wiley.com/doi/10.1046/j.1526-4637.2001.002001028.x/full


I don't think approach matters. Do what you feel most comfortable doing.

View attachment Assessment of Celiac Plexus Block.pdf
View attachment Splachnic nerve block in cancer patients seems to work.pdf

I'm probably in the minority, but I would switch the patient to methadone.

 

[drf]

When I first started out I had 4 repeat celiacs. All were done at L1 with phenol. I did the original block in 2 and someone else did in 2.

I repeated all of them with 100% etoh at T12 and all actually got benefit with the second go.

After that experience I switched to only using 100% etoh and at T12. Haven't needed to repeat since, as far as I know, except for 9-12 months later in a couple who were still alive.