Saint Joseph's University Medical Center Paterson, NJ
Introduction: Celiac plexus blocks (CPB) and celiac plexus neurolysis (CPN) have been implemented to decrease opiate dependency and treat chronic pancreatitis and/or pain resulting from pancreatic malignancy. There are various approaches to facilitate CBP/CPN including percutaneous, surgical and endoscopic, guided as CT, fluoroscopy, US or EUS techniques. EUS is the latest development in CPB/CPN and the least commonly utilized method, however recent studies have shown high efficacy and minimal complications or risks. Despite various complications associated with different techniques, no case report or current literature has documented the development of Iatrogenic Cushing’s disease from 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.
Case Description/Methods: A 27 YO F presented to the ED with severe epigastric pain associated with nausea. She was diagnosed with chronic pancreatitis a year and a half prior. At that time, she underwent an EUS showing severe chronic pancreatitis with biopsies positive for benign pancreatic tissue, fibrotic stromal tissue and scattered eosinophilic infiltrates. Due to recurring pain a subsequent nerve block was repeated. She was prescribed hydromorphone 4 mg q3h as needed, methadone 30 mg BID and Pancrealipase, however a celiac plexus block was repeated due to refractory pain. Upon follow up, she endorsed a 10 lb weight gain, fatigue, acne, facial hair and fullness, dark abdominal striae and insomnia. She was suspected to have iatrogenic cushingoid features due to multiple celiac nerve blocks. A morning cortisol level was 0.3 ug/dL but a salivary cortisol level with within normal limits (< 0.010 ug/dL). She was referred to Endocrinology, who recommended withholding steroids for 3 to 6 months. Repeat testing with ACTH and DEXA suppression confirmed adrenal insufficiency. Five months later, the patient’s pain returned, and her methadone was increased. Repeat EGD/EUS showed pancreatic parenchymal abnormalities consisting of hyperechoic strands, hyperechoic foci and lobularity throughout the entire pancreas. Due to refractory pain, she was referred for a pancreatic transplant program.
Discussion: EUS-guided CPB is an effective, minimally invasive modality in treating pain from abdominal malignancy and/or pancreatitis, however future studies are warranted to evaluate the agents used for chemical destruction, to avoid complications such as Iatrogenic Cushing’s disease.
