most patients with acute calculous cholecystitis have had attacks of severe pain often referred to as biliary colic and which is caused by the obstruction of the gallbladder neck by a bile - duct stone . when conservative treatment , rather than cholecystectomy , is selected , the patient is treated with antibiotics and intravenous fluids during the acute phase . the patient then undergoes procedure for symptom improvement and stone removal , such as percutaneous transhepatic biliary drainage ( ptbd ) with or without tract dilatation ( td ) . although ptbd and td are very painful procedures , they are commonly conducted at our hospital with the patient under moderate sedation using local anesthesia and opioid administration . an ultrashort - acting opioid can also be utilized for the management of painful radiologic procedures . however , it is well - known that opioid administration can lead to side effects such as pruritus , delirium , sedation , respiratory depression , altered gut motility , sphincter of oddi spasm , and constipation . therefore , these opioid side effects may limit the sufficient administration of opioid for pain control . celiac plexus block ( cpb ) is an interventional procedure used for diagnostic and therapeutic purposes in the treatment of visceral pain in the upper abdomen . the main indication for cpb includes visceral abdominal pain refractory to analgesic interventions , and which emanates from the pancreas , stomach , liver , biliary tract , kidney , small intestine , colon , and adrenal glands . these types of pain have been treated with cpb in order to decrease theoretically the side effects of opioid medications and to enhance analgesia caused by medications . here , we present the case of a patient who underwent ptbd and td under cpb in order to reduce biliary procedure - related abdominal pain . a 37-year - old male patient ( 167  cm ; 74  kg , no past medical history ) was admitted with symptoms of fever ( 37.7  c ) , ruq pain , jaundice , nausea , and dyspepsia . the laboratory examinations revealed the following : serum total bilirubin 7.5  mg / dl ; direct bilirubin 5.0  mg / dl ; ast 168 the computed tomography findings showed a 1-cm , dark signal intensity lesion in the proximal common bile duct ( cbd ) as well as bile - duct obstruction . the patient was diagnosed with acute cholecystitis with a cbd stone and was planned to be performed endoscopic retrograde cholangiopancreatography . the stone removal with endoscopic retrograde cholangiopancreatography failed due to a distal cbd stricture and the patient underwent emergency ptbd for symptom improvement . after the ptbd , as the patient complained of severe abdominal and ptbd insertion site pain ( numerical rating scale [ nrs ] 89 ) , pethidine ( 25  mg ) was injected 3 times . following the pethidine injections , as the patient complained of severe nausea with vomiting , metoclopramide ( 10  mg ) however , the stone was not removed after ptbd due to a cbd stricture ( fig . 1 ) . the interventional radiologist planned td with a ptbd procedure and consulted our department in order to manage the patient 's pain during the intervention . the stone ( arrow ) in the proximal common bile duct still remained after ptbd . as the patient was reluctant to receive further opioid administration and did not want to experience nausea and vomiting after the opioid administration , we initially planned a thoracic epidural block after epidural catheter insertion without opioid administration . however , the patient refused during the process of obtaining informed consent due to the possible side effects of a thoracic epidural block . therefore , we considered cpb for his right upper abdominal pain during the td and ptbd procedure . after the patient was informed regarding and understood the effects and possible complications of both thoracic epidural block and cpb skin infiltration for local anesthesia was performed using 1% lidocaine and with the patient in the prone position . right - side cpb using a posterior retrocrural approach at the t12-l1 level and using a bent tip needle with 0.25% bupivacaine ( 10cc ) under fluoroscopy was performed in order to reduce the patient 's pain during and after td and the ptbd procedure ( fig . the patient was changed into the supine position and underwent td and ptbd without severe pain or inconvenience ( fig . although td was in progress , ephedrine ( 5  mg ) was injected once and crystalloid ( 350  ml ) was infused due to hypotension ( 70/40 ) which immediately recovered . anteroposterior ( a ) and lateral ( b ) fluoroscopy image obtained during the celiac plexus block ( cpb ) during tract dilatation ( c ) . in the prone position , the right side of the cpb was performed using a posterior retrocrural approach utilizing a bent tip needle with 0.25% bupivacaine ( 10cc ) under fluoroscopy ( a and b ) . the patient was changed into the supine position and underwent tract dilatation and percutaneous transhepatic biliary drainage . the common bile duct stone ( arrow ) is shown as a filling defect in the posteroanterior view ( c ) . after transfer to the ward , the patient also did not complain of right upper abdominal pain . but the patient complained of moderate pain ( nrs 5 ) at the ptbd insertion site , tramadol ( 50  mg ) was injected only once . mild insertion site pain ( nrs 3 ) continued for approximately 1 day after td and the ptbd procedure . although the patient will be planned to discharge after td and ptbd procedure , discharge was postponed due to fever of the patient . after 14 days of antibiotic treatment , the stone was removed using percutaneous transhepatic choledochoscopy . patients with acute cholecystitis with cbd stone suffer from inflammation , jaundice , and biliary colic . the procedures ( ptbd and td ) for symptom improvement and cbd stone removal are the cause of the pain . as opioids are commonly used for pain control during these procedures , we must consider the side effects of the opioids . our patient was already suffering from ptbd procedure pain and a radiologist consulted to our department regarding his intractable abdominal pain management . with our institutional protocol for this situation , monitored anesthesia care is often performed with an opioid in addition to propofol or dexmedetomidine . however , the present patient did not want opioid treatment and sedation during the procedure because he experienced severe nausea and vomiting after opioid administration . although we considered thoracic epidural block after epidural catheter insertion for pain control during the biliary procedure and after the procedure , the patient refused the thoracic epidural block . therefore , we considered right side cpb for pain control during the biliary procedure . indeed , cpb is a valuable adjunctive therapy for managing upper abdominal pain associated with chronic visceral pathology . right side cpb using a posterior retrocrural approach has successfully reduced pain during ptbd and td , and only transient hypotension was observed during the procedure . furthermore , post - td pain was also controlled without additional opioid administration even with a remaining stone . this is our first experience indicating that cpb may be a useful alternative method for pain control during a bile duct interventional procedure . the present case report is of significance in that cpb during a bile duct interventional procedure can reduce pain and opioid overdose without severe complications . cpb can be a useful alternative technique for pain management during and after a bile duct interventional procedure , although cpb - induced complications must always be kept in mind . the patient signed informed consent for the publication of this case report and any associated images .
abstractalthough percutaneous transhepatic biliary drainage ( ptbd ) and tract dilatation ( td ) are very painful procedures , almost all of those procedures have been conducted under local anesthesia and opioid injection due to the lack of manpower and time . 
 celiac plexus block ( cpb ) is an interventional technique used for diagnostic and therapeutic purposes in the treatment of abdominovisceral pain . 
 cpb decreases the side effects of opioid medications and enhances analgesia from medications . 
 we present the case of a patient who underwent ptbd and td under cpb in order to reduce procedure - related abdominal pain.cpb can be a useful alternative technique for pain management during and after biliary interventional procedures , although cpb - induced complications must always be kept in mind .