 Hello, I am Dr. Sumera Rafiq, junior resident in the Department of Radio Diagnosis at Kasthubha Medical College, Manipal. My topic for poster presentation is computed tomography guided celiac plexus block for intractable abdominal pain, a case series. Ames and methods include to highlight the role of CT guidance in performing celiac plexus block, to discuss the various approach routes and the safety of this procedure in elevating intractable abdominal pain due to upper abdominal malignancies. Introduction Abdominal pain is a debilitating problem in patients with abdominal malignancy and often affects quality of life and survival. An effective means of elevating the intractable pain associated with abdominal malignancy is to disrupt nossy septive impulses at the level of celiac plexus or the splanctinic nerves. Celiac plexus is a network of nerve fibers that are located in the retroperitoneum along the anterolateral wall of the iota. Celiac plexus block refers to the temporary disruption of pain transmission where the celiac plexus and this is accomplished by injecting corticosteroids along acting local anesthetics. Celiac plexus neurolysis refers to permanent destruction of the celiac plexus with ethanol. These two terms are often used interchangeably. We present four cases of patients with chronic upper abdominal pain who wonder when celiac plexus block for pain alleviation. So moving on, the anatomy of the celiac plexus is the largest visceral plexus consisting of the celiac, the superior miscentric and the iota renal ganglia that carry nossy septive stimuli from the upper abdominal viscera. It's located deep in the retroperitoneum near the origins of the celiac axis and superior miscentric artery, composed of visceral afferent fibers and preganglionic sympathetic and preganglionic parasympathetic efferent nerve fibers. The position of celiac ganglia varies anywhere from T12 to L1 displace to the middle of L2 vertebral body. In cross-sectional anatomy, both ganglia are visualized in most of the patients and the left ganglia is seen more often than the right. On axial CT images, it demonstrates a characteristic, discoid or multi-lopulated configuration and attenuation resembles the limbs of the adjacent adrenal gland. It is most consistently seen at the level of the pancreas and the diagnostic feature of a celiac ganglion on contrast enhanced imaging is the presence of persistent contrast enhancement on delayed images. This is a coronal MIP image which shows the position of the common hepatic artery, the spleenic artery and the celiac axis with the position of the celiac ganglia. Same images which is seen on axial. Pre-procedural evaluation, establishing a coagulation profile, apart from that we need to complete a pre-procedural neurologic examination and record the patient's baseline pain. Using an IV axis before the procedure since fluid replacement may be required and cessation of analgesics which is advised for 12-24 hours prior to the procedure. The most commonly used neurologic agent is ethanol which causes irreversible damage to neurons and now fibres and this occurs optimally at an ethanol concentration of more than 50%. So a concentration of between 50-100% is preferred for celiac plexus neuralisis. A mixture of absolute ethanol, bupivacane and contrast material in a ratio of 6 is to 3 is to 1 is most frequently used. Patient preparation includes nilpororal for 8 hours prior to the procedure. Anticoagulants which are temporarily discontinued to minimize the risk of bleeding. Other medications should be continued in the pre-procedural period and monitoring of vitals is essential. The first step in CT guided celiac plexus neuralisis or block is pre-procedural planning wherein we plan the patient position, the CT approach, needle entry site, needle path and site of neurologic agent injection. The patient position is variable, it can be either prone, lateral decubitus, supine, oblique. The most commonly used position is prone since it is the shortest and least complicated route to the celiac plexus. Use of an anterior approach necessitates traversing organs such as liver and stomach before reaching the celiac plexus. Neurolytic injection sites would be anti-cruel that is in the space anterior to the diaphragmatic crura and niota. And this is the most common site of neurologic agent injection and is highly effective in achieving pain control because this directly destroys the celiac plexus whereas in the retrocruel site it is injected into the space behind the diaphragmatic crura and is most performed frequently with the posterior approach. It prevents the neurologic agent from spreading into the celiac plexus. A sterile field is created at the point of needle entry, subcutaneous infiltration with 1% lignocaine is carried out following which a chiba biopsy needle is advanced and the needle tip position is between the celiac trunk and SMA. So 5 ml of diluted iodinated contrast material is injected following which free diffusion of contrast material is documented and approximately 40 ml that is 20 ml on each side of absolute ethanol is injected through the needle into the surrounding space. So various approaches for this technique includes the anterior parliotic approach, the bilateral posterior paravertical anti-cruel or retrocruel approach, posterior transintervertible disc approach and posterior transiotic approach. Direct tumor infiltration involves dual therapeutic purpose of ethanol mediated tumor ablation and necrosis of celiac plexus which ultimately produces the analgesic effect. So this is a CT image depicting bilateral posterior paravertical retrocruel approach and this image depicts posterior transiotic approach. Hydrodesication is performed using 0.9% saline solution wherein there is displacement of organs from the percutaneous path using fluids which are sterile and it is used to prevent pneumothorax. Most procedural care includes bed rest because there is a risk of hypotension, monitoring of vitals, adequate IV fluid replacement, screening for neurological complications and success of procedure is documented by reduction in patient's pain intensity. Most common complication of this procedure is back pain apart from that orthostatic hypotension, transient diarrhea and neurologic injuries. So our first case is that of a 35 year old female who had advanced metastatic carcinoma of tail of pancreas. So once the block was performed her pre-procedural pain scale reading was 8 on 10 whereas post-procedural scale was 2 on 10. As we can see this was the planning phase of the block, positioning of the needle which was confirmed on CT, injection into the right side and the left side. Our second case is that of a 24 year old female, case of acute on chronic calcific pancreatitis, pre-procedural pain was 6 to 8 on 10 whereas immediate post-procedural pain was 2 out of 10. This is the image depicting needle positioning and the injection consequently. Case 3 is that of a 63 year old male who was diagnosed with chronic atropic pancreatitis and carcinoma head of pancreas who had pain since 5 months and pre-procedural pain scale was 4 to 6 out of 10 post-procedural 2 on 10. Image depicting the planning, positioning, injection and the check, post-injection. Case 4 is that of a 29 year old male with recurrent acute on chronic pancreatitis, complaint of pain abdomen since 2 weeks, pre-procedural pain scale was 6 on 10 and post-procedural was 3 on 10. Image depicting the planning, positioning of the needles and the injection of the neurolytic agent, post-injection which is also seen on coronal imaging. Results all 4 patients who underwent the procedure reported a significant reduction in pain post-procedure. Follow-up of these patients showed decreased dependence on analgesic medication for pain management thereby reducing the incidence of drug related adverse effects in the future. CT plays an important role in the guidance of neurolytic aplexus blocking especially in planning and this procedure offers improved pain control and reduces the amount of narco and analgesics. These are my references.