Tracheoesophageal Fistula (TEF)

00:01 In this lecture, we’re going to discuss tracheoesophageal fistula.

00:06 So TEF or tracheoesophageal fistula is an abnormal congenital connection between the trachea and the esophagus.

00:16 There are five types.

00:19 Type 1 is by far the most common.

00:22 This is an atresia with a fistula between the distal esophagus and the trachea as is pictured here.

00:29 You can see the esophagus basically stops.

00:33 The stomach is connected to trachea.

00:36 So these patients will show up very, very early.

00:39 Their first meal, it ain’t going anywhere. They’ll spit up.

00:44 A smaller percentage, 8%, have a completely atretic stomach and esophagus.

00:50 In other words, there’s not fistula.

00:52 There’s simply a blind and looped esophagus and a blind and looped stomach.

00:57 These infants should have no gas bubbles in their intestines on an X-ray, and will spit up very quickly after eating.

01:03 This represents 8%.

01:05 You can see we’ve already accounted for most of tracheoesophageal fistula.

01:10 Almost the rest are the third type and this is an H type of fistula.

01:16 The H type fistula is basically a connection between the trachea and the esophagus.

01:23 There’s a little bridge.

01:25 So these infants are interesting and that they can present a little bit later on.

01:31 Basically, at some point, their gastric contents do dribble into the lungs and they get respiratory distress often with eating.

01:39 So this is fistula without any atresia compared too the last one, which was an atresia without any fistula.

01:46 There are two other very rare types that you might hear about.

01:50 One is where the proximal esophagus feeds into the trachea.

01:54 There is no path to the stomach.

01:57 The other is the same except there is a path to the stomach, the proximal esophagus enters the trachea and then the distal esophagus arises from the trachea a little bit farther down.

02:10 When we see TEF, about half of patients will have an associated anomaly.

02:16 An example might be CHARGE syndrome.

02:19 In CHARGE syndrome, they may have coloboma as you can see in this patient here with that black pupil that’s extending down in the patient’s left eye.

02:28 They may have heart defects or an atresia such as choanal atresia.

02:33 Or they may have retardation or what we like to call intellectual disability.

02:38 They may have genital malformations or they may have ear anomalies.

02:42 CHARGE, C-H-A-R-G-E, and those are symptoms they may have.

02:47 They may also have tracheoesophageal fistula.

02:51 Another defect more classically associated with tracheoesophageal fistula is VACTERL.

02:57 Again, each of these letters count for a symptom that these patients have.

03:01 V is vertebral defects.

03:03 A is anal atresia.

03:05 C is cardiac defects, particularly a VSD and the TE stand for tracheoesophageal fistula.

03:14 They also have renal anomalies or malformations and they have limb defects such as radial dysplasia, polydactyly or syndactyly.

03:24 So most TEF presents almost immediately after birth.

03:30 These patients have food that cannot get into the stomach in most cases.

03:35 This results in immediate emesis and rapid dehydration outside of the uterus.

03:41 Additionally, gastric contents may enter the lungs resulting in respiratory distress.

03:49 So the diagnosis of TEF is usually made because it’s impossible to get the NG tube into the stomach.

03:56 These infants are sick.

03:58 We place an NG in and we can’t get it into the stomach.

04:01 Instead it coils up in the proximal esophagus.

04:04 So we put in the NG, we take an x-ray and, wow, look at that NG, it didn’t go in.

04:09 Maybe this child has a TEF.

04:12 Alternatively we can make a more definitive diagnosis by doing endoscopy.

04:18 We scope, we look down there, it’s a blind loop.

04:22 So the H type fistula is the one I think that comes to mind the most often because it’s more subtle.

04:31 This is only four percent of all cases of TEF.

04:35 But this one can present later on in life.

04:38 It’s basically a fistula that’s small.

04:41 So there can be a delay in diagnosis.

04:44 Patients present with coughing, wheezing, and struggling with feeds and reflux.

04:51 As you can see in this picture, the food goes down the esophagus and then somehow gets into the trachea and can cause problems.

04:59 Some of the food keeps going.

05:03 So that’s my summary of TEF in children.

05:07 Thanks for your time.