Hepatic and Splenic Infarction and Bowel Ischemia Following Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis
The patient was a 69-year-old man with a history of small cell lung cancer with pancreatic metastasis. He received radiotherapy and chemotherapy, which were completed in September 2011. He suffered from debilitating, significant epigastric pain for several weeks before being offered CPN.\nThe procedure was performed under direct EUS visualization with linear array endosonography (Linear EUS Olympus GF-UCT240; Olympus, Tokyo, Japan) used to obtain sagittal views of the celiac trunk. The needle was inserted via the transgastric approach, under EUS guidance, immediately anterosuperior to the takeoff of the celiac trunk. Color Doppler EUS procedure was performed to rule out vessel penetration. After insertion of a 22-gauge needle, an aspiration test was performed in front of the celiac trunk with no blood return, and then 5 mL of 0.25% bupivacaine, 10 mL of dehydrated 98% ethanol, 1 mL of triamcinolone acetonide, and 3 mL of normal saline were injected gradually ().\nOn postoperative day (POD) 1, the patient complained of recurrent abdominal pain, abdominal distension, nausea, and vomiting. On POD 5, a 38℃ high fever developed. Abdominal computed tomography revealed infarction of the left lateral segment of the liver and spleen and ischemia of the stomach and proximal small bowels (, ). On POD 6, bloody diarrhea and hematemesis were observed. On esophagogastroduodenoscopy (EGD), diffuse erythematous, edematous, exudative, and hemorrhagic mucosal changes were noted on the body and multiple gastric ulcers were noted in the antrum without active bleeding (). Hemorrhagic duodenitis and a duodenal ulcer were also visualized. Oral feedings were withheld from the patient, followed by treatment using a proton pump inhibitor and sustained total parenteral nutrition. There was no further hematemesis or hematochezia. The patient continued to suffer from abdominal pain, which improved only partially; it could not be controlled with a continuous intravenous infusion of morphine and use of a fentanyl patch. On POD 12, EGD still showed hemorrhagic gastritis with necrotic debris on the posterior wall of the body and revealed healing stage gastric ulcers on the antrum (). The patient continued to suffer from abdominal pain, nausea, vomiting, and bloody diarrhea. He died 27 days following CPN due to multiorgan failure and sepsis despite best supportive care.