A 17-year-old male presented with chronic abdominal pain of 15 months duration. The patient reported that pain was more prominent in the right lower quadrant, stabbing in nature, episodic, aggravated by food intake and not relieved with antacids and proton pump inhibitors. The pain was rated as high as 10 on the numeric rating scale, which is 0-10, 0 being no pain, 10 being worst pain. Other complaints included reflux of partially digested food after eating, nausea, and vomiting, decreased oral intake, and weight loss. The patient did not have any other comorbid illnesses. He was admitted to the hospital three times for similar complaints and underwent extensive diagnostic investigations including complete blood count, complete metabolic panel, serum amylase, serum lipase, urinalysis, stool studies, Helicobacter pylori antigen, ELISA for Lyme disease, Clostridium difficile PCR, erythrocyte sedimentation rate, c-reactive protein, antinuclear antibody, SS-a and SS-b antibody, X-ray abdomen, ultrasound abdomen/pelvis, computed tomography (CT) of abdomen and pelvis, magnetic resonance enterography, capsule endoscopy, gastric emptying study, and Meckel's scan. All of the tests were unrevealing. Upper gastrointersinal endoscopy and colonoscopy were normal. Biopsies from esophageal, gastric, duodenal, terminal ileum, and colon were negative for organisms such as H. pylori, inflammation, granulomas, or viral cytopathic changes. Magnetic resonance imaging of brain was also normal, which ruled out intracranial etiologies of nausea and vomiting.
Therapeutically, he was treated with acetaminophen, ketorolac, ibuprofen, dicyclomine, and amitriptyline with little or no symptomatic relief. As there was high suspicion of appendicitis based on clinical symptoms and examination, an appendectomy was done. He was asymptomatic for ~3 months after surgery and then he started experiencing severe abdomen pain centered mainly in the epigastrium. Abdominal vascular ultrasound and CT angiography of abdomen were done. Finding suggested impression on the celiac artery by the MAL with poststenotic dilatation. He was then referred to a surgeon who specialized in MAL release for surgical management of possible MALS. However, due to patient's worsening abdomen pain and inability to tolerate food intake, he was admitted to the hospital. He was referred to inpatient pain management for diagnostic CPB to further confirm the diagnosis of MALS.
The patient was brought to the radiology suite. He was given deep sedation under monitored anesthesia care. Retrocrural two-needle approach was used under anteroposterior and lateral fluoroscopy. Correct needle position was confirmed by omnipaque contrast spread under live fluoroscopy. Subsequently, a total of 10 mL of 0.25% bupivacaine was injected on each side. As the surgeon and the patient's family wanted the block to be truly diagnostic, no steroid or additives were included in the block. Patient reported improvement of pain within 30 minutes of procedure. Pain relief lasted for 9 hours postprocedure. That evening, the patient was able to tolerate a full dinner without postprandial pain, which he had not been able to do prior to the procedure. After 9 hours, the pain returned and quickly became intolerable. He had a prolonged hospital course requiring intravenous opioids, pediatric intensive care unit stay for the severe refractory pain, placement of nasojejunal tube for feeding, and eventual discharge on sublingual morphine as needed. Given successful diagnostic block and associated clinical improvement in immediate postblock period, he was scheduled for MALS surgery