Purpose or Case Report: A 17-year-old female presents with the chief complaint of recurrent epigastric pain following the diagnosis of median arcuate ligament syndrome (MALS) confirmed via ultrasound duplex and computed tomography angiography. Subsequent laparoscopic median arcuate ligament release and resection of celiac nerve plexus were performed. The patient initially had complete resolution of pain; however, the same type of epigastric pain recurred with no sonographic evidence of recurrent MALS. This prompted the use of a celiac plexus block for diagnostic and therapeutic purposes. Using a one-sided posterior approach, the expected location of the celiac nerve plexus was localized using 3-dimensional cone-beam computed tomography-guided imaging. Using intermittent fluoroscopy with laser and iGuide graphic overlay the needle was incrementally advanced; to confirm the periaortic location of the needle tip a small amount of dilute contract was injected. Then, 80 mg (40mg/mL) of triamcinolone and 20 mL of 0.5% bupivacaine hydrochloride was administered into the periaortic space. The patient had a complete resolution of pain for two weeks. To obtain long-term pain relief, the process was repeated with an injection of 10 mL of 99% ethanol to effectively ablate the celiac nerve plexus, along with 20 mL of bupivacaine liposome. At 1 month and 3 months post-injection, the patient reports a significant reduction in epigastric pain (0-1 out of 10) following the procedure and reports being pleased she had the procedure. This case expands the use of computed tomography-guided celiac plexus ablation by showing effectiveness in reducing epigastric pain in a pediatric patient with a prior MALS diagnosis.
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