Case of Refractory Hypertension Controlled by Repeated Renal Denervation and Celiac Plexus Block

Abstract

, which is higher than the average body mass index among Korean women. She had a history of ulcerative colitis currently under remission, and she had a history of preeclampsia 3 and 5 years previously. She had 2 children. She had type 2 diabetes mellitus and was taking regular oral medication. She also had recurrent urinary tract infections. She complained of headache, nausea, vomiting, and blurred vision.Blood and urine tests were performed. Except for abnormal fasting glucose and hemoglobin A1C, most tests were within the normal range. Her thyroid function was normal, and her albumin:creatinine ratio in the urinary analysis was slightly above the reference range at 41.34. Her electrocardiagram (ECG) showed no evidence of left ventricular hypertrophy or any other abnormalities. Her left ventricular systolic function was normal and left ventricular mass index at 61.8 g/m 2 was within the normal range. We consulted the Ophthalmology Division as she complained of blurred vision. Ophthalmological examination revealed no retinal abnormalities.We proceeded to follow the algorithm for resistant hypertension ( Figure 1).1 The first step is to exclude white coat hypertension; second, to identify and reverse contributing factors; and third, to discontinue and minimize potential interfering factors and perform screening for secondary causes of hypertension.Ambulatory blood pressure monitoring (ABPM) revealed a high average blood pressure. Therefore, we excluded white coat hypertension. Central pressure analysis showed a high central pressure. Measurement of blood pressure in all 4 limbs showed similar values.We evaluated the patient for possible pheochromocytoma. Her plasma metanephrine and normetanephrine levels were within the reference range. We performed 24-hour urinary collection for metanephrine repetitively, but the values were within the reference range. We performed a positron emission tomography-computed tomography to explore a possible mass because she had fever of unknown origin. A positron emission tomography-computed tomography, which was performed 5 months previously, showed no abnormal metaiodobenzylguanidine (MIBG) uptake.Magnetic resonance imaging (MRI) of the renovasculature, to exclude renovascular hypertension, showed normal renal arteries. Evaluation of hyperaldosteronism or Cushing syndrome showed normal renin and aldosterone levels with no increase in the aldosterone:renin ratio. An overnight dexamethasone suppression test revealed normal response, and the 24-hour urinary cortisol level was within the reference range. An MRI of the brain was performed when she complained of blurred vision and headache. There was no focal lesion in the pituitary fossa or brain parenchyma; therefore, we excluded pituitary adenoma.Next, we examined the plasma hormone levels. Plasma hormone levels were also within the reference range, and an insulin-induced hypoglycemia test was normal.The patient had poor urinary output despite taking diuretics. She drank >2 or 3 L of water daily, but her urinary output was just <1 L....

Pain Outcomes After Celiac Plexus Block in Children and Young Adults with Cancer

“…2,3 CPB has also been employed more broadly for refractory hypertension and postoperative pain. [4][5][6] Studies have supported earlier use, such as at the time of attempted surgical resection in pancreatic cancer, regardless of preexistent pain, or before aggressive opioid dose escalation. [7][8][9] One study found improved CPB efficacy for pain duration of less than 2 months versus greater than 2 months.…”

“…10 The entirety of the pediatric CPB literature is limited to four patients. 4,11,12 The first case of using neurolytic CPB in a pediatric patient was reported by Tanelian and Cousins 3 in a 4-year-old boy with inflammatory bowel disease. Literature reporting the use of CPB in children with cancer includes a case of a 3-year-old boy with unresectable hepatoblastoma, 11 a 7-year-old child with neuroblastoma, 12 and in a series of three children receiving CPB to control abdominal pain, one patient had metastatic adrenocortical carcinoma.…”

“…13 Indications for CPB unique to the adolescent-young adult (AYA) population are less common, but case reports do exist. 4,14,15 To address the gap in the literature, we reviewed our single institution experience of four children and AYA with intraabdominal malignancies receiving palliative treatment for refractory pain, with focus on pain outcome measures.…”