Teaching Case

A seven-day-old term male child presented with a history of respiratory distress and excessive secretions since 12 hours of life. His initial examination was normal. His mother and the nursing staff reported difficulties in feeding, with frequent regurgitations.

A seven-day-old term male child presented with a history of respiratory distress and excessive secretions since 12 hours of life. His initial examination was normal. His mother and the nursing staff reported difficulties in feeding, with frequent regurgitations. There was no cyanosis, shocking, apnea. A nasogastric tube was passed easily through the nose into the stomach and its presence was confirmed both clinically and in the X- ray of the chest. The chest x-ray showed a right upper lobe atelectasis and antibiotic therapy was started. Blood count, serum electrolytes, glucose, and blood gases values were normal. As there was excessive salivation a possibility of swallowing disorder or fistula tracheoesophageal was considered and a contrasted esophageal examination performed. This showed a fistula arising from the anterior esophagus and extending anterosuperiorly to the trachea The child was immediately taken up for surgery, and type H fistula tracheoesophageal was confirmed. The post-opera-time recovery was uneventful.

Esophageal atresia is characterized by incomplete formation of the esophagus. It is often associated with a fistula between the trachea and the esophagus. Many anatomic variations of esophageal atresia with or without tracheoesophageal fistula have been described^. The most common variant of this anomaly consists of a blind esophageal pouch with a fistula between the trachea and the distal esophagus ( C-type esophageal atresia, 85%). The second most common anomaly is pure atresia without tracheoesophageal fistula ( A-type,10%). The third most common variation is the H-type fistula, which consists of a tracheoesophageal fistula without esophageal atresia( E-type esophageal atresia. 4%). This aberration is more difficult to diagnose clinically. If the fistula is long and oblique, the symptoms may be minimal, and the condition may not be identified for many years. The B (Esophageal atresia with proximal TEF) and D (Esophageal atresia with proximal and distal TEF) type atresia occur in less than 1% Associated congenital anomalies are discovered in approximately one half of infants with esophageal atresia The first sign of esophageal atresia in the fetus may be polyhydramnios in the mother. Clinically, the neonate with esophageal atresia presents with copious, fine, white, frothy bubbles of mucus in the mouth. The infant may have episodes of coughing, choking and cyanosis. These episodes may be exaggerated during feeding. If a fistula between the esophagus and the trachea is present, abdominal distention develops as air builds up in the stomach. The abdomen will be scaphoid if no fistula exists. Other anomalies, such as imperforate anus, skeletal abnormalities or cardiac conditions, may be evident on physical examination, but the physical examination may be otherwise unremarkable. If esophageal atresia is suspected, a radiopaque nasogastric or feeding tube should be passed through the nose to the stomach. In patients with atresia, the tube typically stops at 10 to 12 cm and it may curl in the upper pouch. In cases of suspected esophageal atresia, chest radiographs (posteroanterior and lateral views) should be obtained to confirm the position of the tube. The radiograph should include the entire abdomen. In patients with esophageal atresia, air in the stomach confirms the presence of a distal fistula, and the presence of bowel gas rules out duodenal atresia. Contrast studies are seldom necessary to confirm the diagnosis. Such studies increase the risk of aspiration pneumonitis and reactive pulmonary edema, and usually add little to plain film radiographs. Once a diagnosis of esophageal atresia is established, preparations should be made for surgical correction. Most neonates who undergo repair of esophageal atresia and tracheoesophageal fistula have some degree of esophageal dysmotility. Strictures at the site of the anastomosis are common and may subsequently require dilatation. Recurrence of the tracheoesophageal fistula has been reported and is most common at the site of the primary anastomosis. Approximately one half of patients develop gastroesophageal reflux disease.