We obtained comprehensive consent beforehand from the patient, and we obtained consent to report the clinical experience and publish the accompanying images.
The patient was a 58-year-old woman suffering from lower abdominal pain and vomiting, which gradually worsened from the start of December 2017. An upper gastrointestinal endoscopy revealed multiple gastric ulcers and scars, and lower gastrointestinal endoscopy revealed inflammation in the large intestine. The patient had undergone surgery in 1997 for cervical carcinoma, followed by postoperative radiotherapy that involved irradiation of her pelvis and stomach. On the basis of the symptoms, endoscopy findings, and medical history, the patient was diagnosed with refractory multiple gastric ulcers, enterocolitis, and paralytic ileus due to late radiation-induced sequelae.
As a result of frequent vomiting, the patient had become unable to ingest orally. She was hospitalized in October 2018 and fasted before being placed under central venous nutrition control. Hyperbaric oxygen therapy was started to treat the intractable multiple gastric ulcers and ileus. Thirty treatment sessions were scheduled over a period of approximately 1–2 months. Pentazocine and tramadol were administered to treat the abdominal pain, but these achieved poor results.
At hospitalization, the patient was 155 cm tall and weighed 43 kg. Although she exhibited abdominal distention, no muscular defense or rebound pain was observed. On percussion, the bowel sound was attenuated. A blood examination revealed anemia, slight liver dysfunction, low protein levels, and hypoalbuminemia. An abdominal X-ray showed several small intestinal niveau and extension of the colon and small intestine by intestinal gas (Fig. 1a).
The patient experienced increased lower abdominal pain during bowel movements and felt relieved after defecation. Consequently, we hypothesized that her abdominal pain was due to poor peristalsis of the intestinal tract and that blocking the sympathetic nerve of the intestinal tract would help normalize the peristaltic movement and relieve the pain. The pain was strongest in the lower abdomen at the level of the 12th thoracic nerve. An epidural catheter was inserted via the lumbar1–2 intervertebral space, and continuous epidural anesthesia with 0.2% ropivacaine at 4 ml/h was administered for 1 week, resulting in good control of the lower abdominal pain and defecation. This allowed the tramadol, which promotes constipation, to be discontinued. A block of the inferior mesenteric artery plexus with ethanol was performed, resulting in an immediate improvement in the patient’s bowel movements and defecation, and a reduction in lower abdominal pain, now measured as 3 on a numerical rating scale (NRS = 3). An abdominal X-ray was performed after the block procedure, showing the number of intestinal niveau and the amount of gas had decreased, as compared to that before the block (Fig. 1b). The control of lower abdominal pain was effective, and defecation was noted. Tube feeding was started 4 days after the inferior mesenteric artery plexus block, and oral feeding was started 2 days later.
Twelve days after the block, the patient’s lower abdominal pain increased to NRS 8 and there was recrudescence of the vomiting. An abdominal computed tomography (CT) scan showed dilation of the small intestine, as well as the formation of niveau; however, no bowel obstruction or disruption of blood flow was observed (Fig. 2a).
An upper gastrointestinal contrast examination with contrast medium (Gastrografin®, Bayer Yakuhin Ltd., Osaka, Japan) showed relatively good peristaltic movement of the large and small intestine but poor gastric peristaltic movement. A large amount of food residue was also observed. An epidural catheter was inserted via the thoracic 6–7 intervertebral space for innervation of the upper gastrointestinal tract, including the stomach and small intestine, and continuous epidural anesthesia with 0.2% ropivacaine at 4 ml/h was started. This alleviated the abdominal pain, and the vomiting disappeared.
Approximately 2 weeks later, continuous epidural anesthesia was stopped, and a splanchnic nerve block with ethanol was performed (Fig. 2c). This resulted in an improvement in the lower abdominal pain to NRS 1, as well as an increase in food intake. The following day, CT showed a large improvement in the ileus (Fig. 2b). An upper gastrointestinal contrast examination showed that peristaltic movement of the upper gastrointestinal tract had improved (Fig. 3). The subsequent course was good, and the hyperbaric oxygen therapy was completed. The patient was discharged from hospital at the end of January. At the outpatient visit 2 weeks later, the general condition of the patient was good and she could orally intake her normal diet.