Lucent Proximal Pouch Bowel

Radiological Findings

The radiological appearance varies with the type of lesion, whether there is esophageal atresia, fistula or both. The initial radiograph must include the entire abdomen to assess for the presence of bowel gas (Figs. 2.5 and 2.6). The abdomen is characteristically gasless in the absence of a fistula, whereas in the presence of a distal fistula, the abdomen has a normal bowel gas pattern. Features of esophageal atresia are characteristic. The proximal blind-ending pouch is lucent and distended with air, often with a coiled esophageal tube. The lateral chest radiograph confirms the distended esophagus which displaces the airway anteriorly, markedly narrowing the tracheal lumen (Fig. 2.7). The cervical esophagus can become quite distended in children on nasal continuous positive airway pressure (CPAP) and have a similar appearance to EA (Walor et al. 2005). A right-sided aortic arch occurs in 5% of children

Oesophagus Gas
Fig. 2.5. Esophageal atresia with distal tracheoesophageal fistula. The orogastric tube tip is in the blind-ending esophagus and gas is present in loops of bowel in the abdomen. Note the right cervical rib and left 13th rib

with EA/TEF and may be difficult to see on the plain chest radiograph of infants (Berdon et al. 1979). Pre-operative echocardiography should be routinely done in these babies to evaluate the heart and the aortic arch in order to plan surgical access on the side contralateral to the aortic arch. The radiograph should be evaluated for vertebral and limb anomalies (Fig. 2.8).

A "pouchogram" of the atretic proximal esophagus is not usually necessary because of the low incidence a fistula from the proximal pouch (Fig. 2.9). In addition, this is a dangerous procedure if improperly performed. Air or non-ionic isotonic contrast medium can be injected to distend the pouch (Fig. 2.10). Over distention of the pouch with contrast medium will invariably result in aspiration so only a small volume of contrast medium, not exceeding 1-2 ml, is injected into the blind-ending pouch with the child in the true lateral position. Contrast medium must be removed at the end of the procedure.

Gasless Abdomen Neonate
Fig. 2.6. Esophageal atresia without distal tracheoesophageal fistula. The abdomen is gasless. Duodenal atresia was diagnosed at the time of surgical repair
Enlarged Stomach Duodenal Atresia

Fig. 2.7. Tracheomalacia. Lateral radiograph with Fig. 2.8. Esophageal atresia with vertebral anomalies. Newborn with the orogastric tube in the distended atretic proxi- EA and a long gap not amenable to primary repair. Pneumoperito-mal esophagus and markedly decreased caliber of neum followed the recent laparotomy. The esophageal tube is in the the airway at the same level blind-ending esophagus. Note the vertebral segmentation anomalies and corresponding missing right sided ribs

Fig. 2.7. Tracheomalacia. Lateral radiograph with Fig. 2.8. Esophageal atresia with vertebral anomalies. Newborn with the orogastric tube in the distended atretic proxi- EA and a long gap not amenable to primary repair. Pneumoperito-mal esophagus and markedly decreased caliber of neum followed the recent laparotomy. The esophageal tube is in the the airway at the same level blind-ending esophagus. Note the vertebral segmentation anomalies and corresponding missing right sided ribs

Esophageal Atresia Barium Swallow

demonstrates esophageal atresia. The abdomen is gasless in the absence of a distal fis- Fig. 2.10. Lateral "pouchogram" with esophageal atresia and proximal tra-tula. The left scapula is winged and elevated cheoesophageal fistula. Contrast medium fills the blind-ending esophageal (Sprengel deformity) pouch and a narrow fistula connects to the trachea demonstrates esophageal atresia. The abdomen is gasless in the absence of a distal fis- Fig. 2.10. Lateral "pouchogram" with esophageal atresia and proximal tra-tula. The left scapula is winged and elevated cheoesophageal fistula. Contrast medium fills the blind-ending esophageal (Sprengel deformity) pouch and a narrow fistula connects to the trachea

An H-type fistula is often difficult to demonstrate. The barium esophagram, performed to evaluate swallowing and possible aspiration, may reveal the TEF (Fig. 2.11). If the barium esophagram is normal, and suspicion of TEF is high in an infant with recurrent aspiration pneumonias or cyanotic episodes, a more invasive investigation is required. For this procedure, the infant is placed on the octagon board in the true lateral position. Prone positioning is not necessary. The lateral position will give the best unobstructed view of the esophagus and airway, and gives the best access for suctioning. The correct examination technique is with a nasogastric tube inserted into the esophagus to the level of the carina. The tube is slowly withdrawn while low-osmolar non-ionic contrast medium is being injected at a rate sufficient to distend the esophagus. The fluoros-copist must always visualize the larynx during the esophagram to be able to differentiate whether tracheal contrast entered through a fistulous connection or by aspiration. The upper cervical esophagus is the commonest location for an H-type fistula, and it is here that greatest care must be taken in order not to overfill the esophagus and cause spill into the airway and aspiration, and also not to miss a subtle

Fig. 2.11. Tracheoesophageal fistula. The fis-tulous connection to the trachea was opaci-fied during the barium swallow examination. The fistula has an oblique cephalad course

fistulous track. The fistulae are muscular tubes that are not constantly open. They are thought to open during respiration and with swallowing. The fistula will be missed if it is temporarily plugged with food or mucus. It is not uncommon for the fistula not to be demonstrated the first time, thus requiring more than one contrast examination.

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