Iatrogenic Cushing’s From Celiac Plexus Blocks for Chronic Pancreatitis: A Case Report

Abstract

Chronic pancreatitis and pancreatic malignancies can result in chronic pain that is difficult to treat with traditional regimens. Various pain management strategies have been implemented to improve the quality of life for patients with these conditions, but these strategies are limited by their efficacy and side effects, including opiate dependence. Celiac plexus blocks (CPB) and celiac plexus neurolysis (CPN) were implemented to decrease opiate dependency and treat chronic pain for pancreatitis and pancreatic malignancy. Numerous approaches are used to facilitate CPB/CPN, including percutaneous, surgical, and endoscopic, guided as computerized tomography (CT), fluoroscopy, ultrasound (US), or endoscopic ultrasound (EUS) techniques. EUS is the latest development in CPB/CPN and the least commonly utilized method; however, it is highly efficacious and associated with minimal complications and/or risks. With endoscopic CPB/CPN, overall mortality improves. Despite the various complications associated with other techniques, no case report or current literature has documented the development of iatrogenic Cushing's disease from the use of steroids during CPB via any approach. Herein, we report the first case of iatrogenic Cushing's disease from CPB in the treatment of chronic pancreatitis. Future studies are warranted to examine the agents used in the chemical destruction for CPB/CPN, to avoid complications such as this.

A case of celiac plexus block causing iatrogenic Cushing's syndrome

“…3 Oral and parenteral steroids are more commonly associated with symptoms of hypercortisolism; nevertheless, this can occur with virtually all pharmacological formulations (Table 1). [8][9][10][11][12][13] Celiac plexus block has been increasingly used for the past decade for treatment of abdominal pain related to pancreatic cancer and chronic pancreatitis. The injection cocktail typically consists of bupivacaine 20 mL and 40-80 mg of triamcinolone (at the endoscopist's discretion), and the patients typically require repeated treatments, every 3-4 months.…”

“…14 To date, there are no published studies assessing the incidence of Cushing's syndrome and adrenal insufficiency associated with CPB, but a recent case report of Cushing's syndrome after CPB was recently reported. 13 Physician awareness of the steroid exposure is critical for establishing the correct diagnosis and for appropriately managing the comorbidities related to hypercortisolism (i.e., diabetes, hypertension, obesity, osteoporosis). Sometimes, this requires additional record review and reaching out directly to the patient's other treating providers.…”

“…The injection cocktail typically consists of bupivacaine 20 mL and 40–80 mg of triamcinolone (at the endoscopist's discretion), and the patients typically require repeated treatments, every 3–4 months 14 . To date, there are no published studies assessing the incidence of Cushing's syndrome and adrenal insufficiency associated with CPB, but a recent case report of Cushing's syndrome after CPB was recently reported 13 …”

“… 3 Oral and parenteral steroids are more commonly associated with symptoms of hypercortisolism; nevertheless, this can occur with virtually all pharmacological formulations (Table 1 ). 8 , 9 , 10 , 11 , 12 , 13 …”

“… 14 To date, there are no published studies assessing the incidence of Cushing's syndrome and adrenal insufficiency associated with CPB, but a recent case report of Cushing's syndrome after CPB was recently reported. 13 …”