Case Reports

Indian Pediatrics 2000;37: 96-97

Inadvertent Passage of Infant Feeding Tube into the Stomach Through a Tracheo-Esophageal Fistula

From the Neonatal Division, Department of Pediatrics, Manipal Hospital, Bangalore 560 017, India.
Reprint requests: Dr. Arvind Shenoi, Consultant Neonatologist, Department of Pediatrics, Manipal Hospital, No. 98, Rustom Bagh, Airport Road, Bangalore 560 017, India. E-mail: [email protected]
Manuscript Received: May 10, 1999; Initial review completed: May 21, 1999;
Revision Accepted: August 18, 1999

Esophageal atresia is a common anomaly. Nearly 85% of cases are associated with a tracheo-esophageal fistula(TEF)(1). In most neonatal units an infant feeding tube is routinely passed after admission to empty the stomach and collect the gastric aspirate. Once it is confirmed that the tip of the tube is in the stomach one assumes that there is no esophageal atresia. We report here an instance where this assumption led us astray

Case Report

A three-day-old term male child presented with a history of respiratory distress and excessive oral secretions since 12 hours of life. There was no history of polyhydramnios. At admission, the child had mild respiratory distress with bilateral crepitations. A nasogastric tube 6Fr was passed easily through the nose into the stomach and its presence was confirmed both clinically and in the X-ray of the chest. As there was excessive salivation a possibility of swallowing disorder or dysmotility was considered and a barium swallow examination performed. This showed esophageal atresia with the nasogastric tube which had passed through the trachea, TEF into the stomach. There was aspiration of the barium into the bronchi (Fig. 1). The child was immediately taken up for surgery, the fistula was identified and ligated. Primary anastomosis was done between the two ends of the esophagus. The post-opera-tive recovery was uneventful. The boy is now 2 years old and is doing well on follow up.

Fig. 1. Barium swallow examination delineating the infant feeding tube passing into trachea, TEF and esophagus. Blind upper esophageal pouch and bronchi are also seen due to spill over of barium.

Discussion

Esophageal atresia occurs 1 in 3000 live births(2). Polyhydramnios during the antenatal period should alert the clinician to the possibility of this condition. However, such a history may not always be available. In most neonatal units there is a routine practice of passing a 5Fr or 6Fr infant feeding tube through the nose soon after admission. If the catheter stops at 8-10 cm the upper gum and roentgenogram shows a coiled catheter in the upper esophageal pouch one can diagnose esophageal atresia(1). On the other hand, if an esophageal atresia is suspected on clinical grounds the ideal test would be to pass a stiff red rubber catheter through the mouth and note the resistance. A barium swallow examina-tion is contraindicated in suspected cases of esophageal atresia.

In this case we did not suspect an esophageal atresia as the infant feeding tube had passed easily into the stomach and this had been confirmed radiologically. The barium examina-tion was done to rule out motility disorders of the pharynx and the esophagus. It proved that we had been led astray. In retrospect, we feel that the error may be avoided if we pass a stiff catheter into the esophagus in all cases of neonatal pneumonia and confirm this radio-logically. This practice has now been instituted in our unit.

References

1. Herbst JJ. Atresia and tracheo-esophageal fistula. In: Nelson Textbook of Pediatrics, 15th edn. Eds. Behrman RE, Kliegman RM, Arvin AM, Bangalore, Prism Books Pvt. Ltd, 1996; pp 1052-1053.

2. Carl FD, Daniel GY. Congenital defects and surgical problems, esophagus and stomach. In: Text book of Neonatology, 2nd edn. Ed. Roberton NRC. Edinburgh, Churchill Living-stone, 1992; pp 660-663.