Review Question - QID 105417

This patient's presentation of choking, reflux, and respiratory distress after their first feeding as well as a chest radiograph showing coiling of the NG tube in the proximal esophagus is suggestive of esophageal atresia.

Esophageal atresia should be suspected in infants with excessive drooling accompanied by choking or coughing as well as significant reflux after their first meal. Infants swallow normally but then begin to cough and choke as the fluid backs up and refluxes into their nose and mouth. Cyanosis and respiratory distress are caused by fluid overflowing from the esophageal pouch and being aspirated into the trachea. Esophageal atresia may be detected prenatally on ultrasound, with findings of polyhydramnios or a small gastric bubble; however, this has relatively low sensitivity.

Clark reviews the presentation and management of esophageal atresia and tracheoesophageal fistula. Esophageal atresia occurs in 1:3,000-5,000 births and is often associated with other conditions. Esophageal atresia commonly occurs with tracheoesophageal fistula, with the most common variant (84%) being a blind proximal esophageal pouch and a fistula between the distal esophagus and trachea. Aside from tracheoesophageal fistula, these associations include: vertebral defects, anorectal malformation, cardiac anomalies, renal anomalies, radial dysplasia, and limb defects (VACTERL).

Pinheiro et al. discuss the management of esophageal atresia. Primary surgical correction is the preferred treatment for esophageal atresia and tracheoesophageal fistula. This surgery is more difficult in cases where there is a long gap between the esophageal pouch and the distal esophageal connection to the trachea. Surgical complications of this procedure can include anastamotic leak or stenosis, gastroesophageal reflux disease, or esophageal dysmotility.

Figure A is a chest radiograph of a neonate with esophageal atresia; note the coiling of the NG tube in the proximal esophageal pouch. Illustration A shows the different types of esophageal atresia and tracheoesophageal fistula; note that type C with the proximal esophageal pouch and distal esophageal-tracheal fistula is the most common presentation.

Incorrect Answers:
Answer 1: A laryngotracheoesophageal (laryngeal) cleft is a rare anatomic abnormality where the trachea and esophagus may be connected from the carina to the larynx due to failed development of the septum between these two structures. The presenting symptoms of coughing, reflux, respiratory distress are often similar to esophageal atresia; however, the esophagus is typically patent in this condition, allowing for passage of the NG tube. Additionally, overall esophageal atresia is a much more common congenital abnormality, 1:3,000-4,500 vs a laryngeal cleft being a much rarer event.
Answer 2: Although most newborns experience mild to moderate reflux after feedings, the respiratory compromise and radiographic findings in this case suggest a more serious diagnosis.
Answer 3: GERD may affect infants and cause symptoms of choking, gagging, vomiting, and even trouble breathing; however, the radiographic findings in this case suggest a more serious problem. Reflux in infants typically resolves spontaneously by 1 year of age. The diagnosis of GERD in infants cannot be made after only one feeding.
Answer 5: Pyloric stenosis presents as projectile nonbilious vomiting occurring most commonly in first-born males. Symptoms of pyloric stenosis typically do not manifest with the first feeding but instead present at 2-6 weeks of life.