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ADC-FNN Online First, published on June 25, 2012 as 10.1136/archdischild-2012-301929 Images in neonatal medicine
Images in neonatal medicine Mind the gap: delayed diagnosis of oesophageal atresia and tracheo-oesophageal fistula due to passage of a nasogastric tube
A second attempt at inserting a NGT was unsuccessful and further radiographs showed coiled tubes in the upper oesophagus. The oesophageal continuity was tested with a 10 Fr Replogle tube which stopped at about 10 cm from the nostril. Contrast radiographs with the Replogle in place made the diagnosis of OA/TOF in both neonates (figure 2) and confirmed at surgery.
Two neonates developed sialorrhoea and feeds intolerance. A nasogastric tube (NGT) was passed with difficulty and its gastric position confirmed radiologically in both (figure 1A,B). Oesophageal atresia with tracheo-oesophageal fistula (OA/TOF) was therefore ‘excluded’. However, the babies continued to chock with feeds.
DISCUSSION Newborns with OA/TOF can tolerate a small NGT that passes through the larynx, the trachea, the fi stula/distal oesophagus and reaches the stomach.1–3
Figure 1 (A, B) In both babies the babygram showed the ‘correct’ position of the nasogastric tube, with the tip lying in the stomach.
Figure 2 The contrast instilled via the Replogle tube outlined a blind-ending upper oesophageal pouch extending to just below the thoracic inlet. A similar picture was seen in the other baby.
Soccorso G, England RJ, Godbole (or PP, ettheir al. Archemployer) Dis Child Fetal Neonatal (2012). doi:10.1136/archdischild-2012-301929 of F2 Copyright Article author 2012.EdProduced by BMJ Publishing Group Ltd (& RCPCH) underF1licence.
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Images in neonatal medicine ‘Successful’ passage of the NGT is often defi ned by the length of tube inserted and a pH test, but neither test can exclude passage to the stomach by an abnormal route. An antero-posterior fi lm might highlight a minor deviation from the midline4; a lateral chest x-ray is not routinely indicated. If a baby remains symptomatic in spite of ‘successful’ passage of a NGT, the possibility of OA/TOF should still be considered, a further attempt at passage of a stiff 10 Fr catheter should be undertaken and, where doubt persists, a contrast radiograph should be performed by an experienced radiologist. 5
Contributors GS designed the study, contributed to the analysis and writing the first draft of the paper. RJE assisted with the design of the study and contributed to the analysis and writing of the paper. PPG, RMF and SSM provided clinical input to the study and contributed to the analysis and writing of the paper. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed. Received 21 February 2012 Accepted 10 May 2012
REFERENCES 1.
Giampiero Soccorso, Richard J England, Prasad P Godbole, Ross M Fisher, Sean S Marven
2. 3.
Paediatric Surgical Unit, Sheffield Children’s NHS Foundation Trust, Sheffield, UK 4.
Correspondence to G Soccorso, Paediatric Surgical Unit, Sheffield Children Hospital NHS Trust, Western bank, Sheffield, South Yorkshire S10 2TH, UK;
[email protected]
F2 of F2
5.
Allgrove J, Husband P, Dickson JA. Cautionary tale of a wandering tube. Lancet 1975;2:815. Spitz L. Esophageal atresia. Lessons I have learned in a 40-year experience. J Pediatr Surg 2006;41:1635–40. Kuti K, Patel R, Chapman S, et al. A rare pitfall in the diagnosis of oesophageal atresia. Pediatr Radiol 2010 May 12 [Epub ahead of print]. Celayir AC, Erdog˘an E. An infrequent cause of misdiagnosis in esophageal atresia. J Pediatr Surg 2003;38:1389. Alexander A, Millar AJ. The passage of a nasogastric tube does not always exclude an oesophageal atresia. Afr J Paediatr Surg 2009;6:47–8.
Soccorso G, England RJ, Godbole PP, et al. Arch Dis Child Fetal Neonatal Ed (2012). doi:10.1136/archdischild-2012-301929
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Mind the gap: delayed diagnosis of oesophageal atresia and tracheo-oesophageal fistula due to passage of a nasogastric tube Giampiero Soccorso, Richard J England, Prasad P Godbole, et al. Arch Dis Child Fetal Neonatal Ed published online June 25, 2012
doi: 10.1136/archdischild-2012-301929
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References
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