Oesophageal Atresia and Tracheo-oesophageal Fistula
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Direct answer
Oesophageal atresia is a discontinuity of the oesophagus, and it is often accompanied by a tracheo-oesophageal fistula that connects the distal oesophagus to the trachea. The commonest form, Gross type C, has a blind upper pouch and a distal fistula. Affected babies present with excessive salivation, choking and cyanosis with feeds, and the antenatal clue is polyhydramnios.
What you must remember
- Gross type C: blind upper oesophageal pouch with a distal tracheo-oesophageal fistula, the commonest type by far.
- Gross type A: pure oesophageal atresia with no fistula, a rarer form.
- Gross type E: an isolated H-type fistula with an intact oesophagus, which presents later with cough and choking on feeds.
- Antenatal clue: polyhydramnios, because the fetus cannot swallow amniotic fluid through an interrupted oesophagus.
- Diagnostic test: a feeding tube that fails to pass, coiling in the upper pouch on a chest X-ray.
- Gas in the stomach: a gas-filled stomach on X-ray indicates a distal fistula, while an absent gas shadow suggests pure atresia.
- VACTERL association: vertebral, anal, cardiac, tracheo-oesophageal, renal and limb anomalies, screened for in every affected baby.
Gross classification at a glance
Gross classification defines the anatomy of the atresia and fistula, and it guides both the diagnosis and the operation. The table below sets out the five types, with their relative frequency. Examiners often ask the commonest type and the one that is easily missed.
| Gross type | Anatomy | Relative frequency |
|---|---|---|
| A | Pure atresia, no fistula | Rare |
| B | Upper fistula with atresia | Very rare |
| C | Distal fistula with upper pouch | Commonest |
| D | Fistulas above and below atresia | Very rare |
| E | H-type fistula, oesophagus intact | Uncommon |
Type C is repaired by dividing the fistula and performing a primary oesophageal anastomosis, when the baby is fit. Type E is easily missed on routine imaging, so it is diagnosed by contrast study or bronchoscopy when aspiration recurs.
Before repair, all types are managed the same way: the baby is kept nil by mouth, the upper pouch is aspirated continuously and the head is kept elevated. Aspiration pneumonia is the main threat in the interval before surgery, so early transfer to a paediatric surgical centre is essential.
Where the exam tries to catch you
Oesophageal atresia questions test the classification, the imaging clues and the associated anomalies.
- Trap: expecting a gas-filled stomach in every case. Correct: a gas-filled stomach indicates a distal fistula, while an absent gas shadow suggests pure atresia without a fistula.
- Trap: screening only the heart and kidneys for associated anomalies. Correct: VACTERL screening covers vertebral, anal, cardiac, renal and limb defects, so the full list must be considered.
- Trap: dismissing H-type fistula because the X-ray looks normal. Correct: the oesophagus is intact in type E, so the diagnosis depends on contrast study or bronchoscopy when recurrent aspiration is present.
Frequently asked questions
What is the commonest type of oesophageal atresia?
The commonest type of oesophageal atresia is Gross type C, in which the upper oesophagus ends in a blind pouch and the distal oesophagus connects to the trachea through a fistula. Gross type C accounts for the large majority of cases. Its diagnosis rests on a feeding tube that fails to pass and a gas-filled stomach on X-ray.
Why does polyhydramnios occur in oesophageal atresia?
Polyhydramnios occurs in oesophageal atresia because the fetus cannot swallow amniotic fluid when the oesophagus is interrupted. The fluid therefore accumulates in the amniotic cavity. Polyhydramnios is a common antenatal clue, though it is not present in every case.
Where does the feeding tube coil in oesophageal atresia?
The feeding tube in oesophageal atresia coils in the upper oesophageal pouch, which is seen on a chest X-ray. The tube fails to pass beyond the pouch, which is the key diagnostic clue. A gas-filled stomach on X-ray suggests a distal tracheo-oesophageal fistula.
What is VACTERL association in oesophageal atresia?
VACTERL association is a pattern of vertebral, anal, cardiac, tracheo-oesophageal, renal and limb anomalies that can occur with oesophageal atresia. Affected babies should be screened for each component, especially cardiac and renal anomalies. The association matters for surgical planning and prognosis.