eMedicine Specialties > Gastroenterology > Esophagus

Tracheoesophageal Fistula: Differential Diagnoses & Workup

Author: Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St. Boniface General Hospital
Coauthor(s): Donald Duerksen, MD, Assistant Professor, Department of Medicine, Section of Gastroenterology, University of Manitoba, Canada
Contributor Information and Disclosures

Updated: Jun 16, 2006

Differential Diagnoses

Esophageal Cancer
Respiratory Failure
Esophageal Diverticula
Tracheal Tumors
Esophageal Rupture
Tracheomalacia
Esophageal Stricture
Zenker Diverticulum
Esophagitis
Gastroesophageal Reflux Disease
Pneumonia, Aspiration

Other Problems to Be Considered

Pharyngeal pseudodiverticulum should be considered in the differential diagnosis of TEFs. This may occur secondary to traumatic perforation of the posterior pharynx from finger insertion into the oropharynx during labor or following vigorous efforts at tube insertion during resuscitation of the newborn. These patients develop pneumomediastinum.

A very rare cause of neonatal respiratory distress is tracheal agenesis, which is always fatal within hours of birth. In tracheal agenesis, a nasogastric tube can be inserted easily.

Zenker diverticulum is also known as posterior hypopharyngeal pouch and pharyngoesophageal diverticulum. This condition involves herniation of mucosa and submucosa through the oblique and transverse fibers of the cricopharyngeus muscle. The blind pouch develops at the pharyngoesophageal junction at the level of the C5-C6 disc space. The pouch is the result of hyperdynamic cricopharyngeal sphincter contraction associated with an abnormality of cricopharyngeal relaxation.

Workup

Imaging Studies

  • Prenatal diagnosis of congenital TEFs: Prenatal ultrasound may reveal polyhydramnios, absence of fluid-filled stomach, small abdomen, lower-than-expected fetal weight, and a distended esophageal pouch.
  • Postnatal diagnosis of congenital TEFs
    • Plain chest radiographs may reveal tracheal compression and deviation. Absence of a gastric bubble indicates esophageal atresia without a TEF or esophageal atresia with a proximal TEF. Chest radiography leads to the diagnosis of TEF in most cases of congenital TEF, and other investigations are rarely required.
    • Aspiration pneumonia in the posterior segments of the upper lobes may occur secondary to aspiration of the contents from the esophageal pouch or stomach. Recurrent or massive aspiration may lead to acute lung injury in some patients. (Infiltrates occur diffusely in these patients.)
    • Insertion of a nasogastric tube may show coiling in the mediastinum of patients who have concomitant esophageal atresia. This finding is diagnostic of TEFs associated with esophageal atresia.
    • Contrast studies are seldom required to confirm the diagnosis. These studies have the risk of aspiration pneumonitis and pulmonary injury, and they add minimal information to the diagnostic workup. If the contrast study is performed, 1-2 mL of barium is instilled through an 8F catheter placed into the esophagus. Chest radiographs are taken in the lateral decubitus position as well as the anteroposterior position to detect spilling of the contrast into the trachea.
    • Use of multidetector-row CT scans have made 3-dimensional (3D) displays of many organs and structures a popular clinical examination tool, as the quality of images has markedly improved. Presence of TEF was correctly diagnosed with multidetector-row CT esophagography. Furthermore, the images provided crucial information for planning surgery, and, without contrast medium, it is a less invasive examination.
  • Diagnosis of acquired TEFs
    • Acquired TEFs can be diagnosed by instillation of contrast media into the esophagus or during direct visualization by flexible esophagoscopy or bronchoscopy. Either method can be useful, depending on the individual center's expertise and experience.
    • Some clinicians prefer to visualize the fistula and assess its exact location prior to surgery. The diagnosis of a TEF secondary to malignancy is confirmed by contrast radiography, esophagoscopy, bronchoscopy, and clinical testing (methylene blue).

Procedures

  • Flexible esophagoscopy or flexible bronchoscopy may be useful in the diagnosis of acquired TEFs. Either or both of these procedures may be required to evaluate the anatomy of these structures and to exclude an unsuspecting mucosal lesion. The role of endoscopic procedures is especially important in localizing the acquired nonmalignant or malignant TEF.

More on Tracheoesophageal Fistula

Overview: Tracheoesophageal Fistula
Differential Diagnoses & Workup: Tracheoesophageal Fistula
Treatment & Medication: Tracheoesophageal Fistula
Follow-up: Tracheoesophageal Fistula
Multimedia: Tracheoesophageal Fistula
References
[ CLOSE WINDOW ]

References

  1. Acosta JL, Battersby JS. Congenital tracheoesophageal fistula in the adult. Ann Thorac Surg. Jan 1974;17(1):51-7. [Medline].

  2. Ashcraft KW, Holder TM. Esophageal atresia and tracheoesophageal fistula malformations. Surg Clin North Am. Apr 1976;56(2):299-315. [Medline].

  3. Bell MJ. Repair of esophageal atresia and tracheoesophageal fistula. Mo Med. Mar 1976;73(3):136-7, 142. [Medline].

  4. Burt M, Diehl W, Martini N et al. Malignant esophagorespiratory fistula: management options and survival. Ann Thorac Surg. Dec 1991;52(6):1222-8; discussion 1228-9. [Medline].

  5. Dogan BE, Fitoz S, Atasoy C. Tracheoesophageal fistula: demonstration of recurrence by three-dimensional computed tomography. Curr Probl Diagn Radiol. Jul-Aug 2005;34(4):167-9.

  6. Engum SA, Grosfeld JL, West KW. Analysis of morbidity and mortality in 227 cases of esophageal atresia and/or tracheoesophageal fistula over two decades. Arch Surg. May 1995;130(5):502-8; discussion 508-9. [Medline].

  7. Flege JB Jr. Tracheoesophageal fistula caused by cuffed tracheostomy tube. Ann Surg. Jul 1967;166(1):153-6. [Medline].

  8. Gerwat J, Bryce DP. Management of traumatic tracheoesophageal fistula. Arch Otolaryngol. Jan 1975;101(1):67-70. [Medline].

  9. Harley HR. Ulcerative tracheo-oesophageal fistula during treatment by tracheostomy and intermittent positive pressure ventilation. Thorax. May 1972;27(3):338-52. [Medline].

  10. Holder TM, Ashcraft KW, Sharp RJ et al. Care of infants with esophageal atresia, tracheoesophageal fistula, and associated anomalies. J Thorac Cardiovasc Surg. Dec 1987;94(6):828-35. [Medline].

  11. Lamis PA Jr, Othersen HB Jr. Esophageal atresia and tracheoesophageal fistula. J S C Med Assoc. Jun 1966;62(6):224-8. [Medline].

  12. Lee LM, Razi A. Three-layer technique to close a persistent tracheo-oesophageal fistula. Asian J Surg. Oct 2004;27(4):336-8.

  13. Leeds WM, Morley TF, Zappasodi SJ. Computed tomography for diagnosis of tracheoesophageal fistula. Crit Care Med. Jun 1986;14(6):591-2. [Medline].

  14. Martin LW, Alexander F. Esophageal atresia. Surg Clin North Am. Oct 1985;65(5):1099-113. [Medline].

  15. Marzelle J, Dartevelle P, Khalife J. Surgical management of acquired post-intubation tracheo-oesophageal fistulas: 27 patients. Eur J Cardiothorac Surg. 1989;3(6):499-502; discussion 502-3. [Medline].

  16. Nagata K, Kamio Y, Ichikawa T. Congenital tracheoesophageal fistula successfully diagnosed by CT esophagography. World J Gastroenterol. Mar 7 2006;12(9):1476-8.

  17. Nagata K, Kamio Y, Ichikawa T. Congenital tracheoesophageal fistula successfully diagnosed by CT esophagography. World J Gastroenterol. Mar 7 2006;12(9):1476-8.

  18. Neale HW, Main FB. Acquired tracheoesophageal fistula: A formidable complication of continued respiratory assistance. South Med J. Sep 1974;67(9):1102-4. [Medline].

  19. Nguyen T, Zainabadi K, Bui T. Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula: lessons learned. J Laparoendosc Adv Surg Tech A. Apr 2006;16(2):174-8.

  20. Pearson BW, Harrison DF. Surgical management of combined cervical tracheo-esophageal defects. Laryngoscope. Sep 1974;84(9):1454-65. [Medline].

  21. Qi BQ, Beasley SW, Williams AK. Evidence of a common pathogenesis for foregut duplications and esophageal atresia with tracheo-esophageal fistula. Anat Rec. Sep 1 2001;264(1):93-100. [Medline].

  22. Robins B, Das AK. Anesthetic management of acquired tracheoesophageal fistula: a brief report. Anesth Analg. Oct 2001;93(4):903-5, table of contents. [Medline].

  23. Shepard R, Fenn S, Sieber WK. Evaluation of esophageal function in postoperative esophageal atresia and tracheoesophageal fistula. Surgery. Apr 1966;59(4):608-17. [Medline].

  24. Shin JH, Song HY, Ko GY. Esophagorespiratory fistula: long-term results of palliative treatment with covered expandable metallic stents in 61 patients. Radiology. Jul 2004;232(1):252-9.

  25. Thomas AN. Management of tracheoesophageal fistula caused by cuffed tracheal tubes. Am J Surg. Aug 1972;124(2):181-9. [Medline].

  26. Vijayaraghavan SB. Antenatal diagnosis of esophageal atresia with tracheoesophageal fistula. J Ultrasound Med. May 1996;15(5):417-9. [Medline].

  27. Williams J. Diagnosing tracheoesophageal fistula without esophageal atresia. Clin Pediatr (Phila). Feb 1996;35(2):103-4. [Medline].

  28. Woolley MM. Esophageal atresia and tracheoesophageal fistula: 1939 to 1979. Am J Surg. Jun 1980;139(6):771-4. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

TEF, fistulae, esophageal atresia, Down syndrome, duodenal atresia, cardiovascular defects, cardiac anomalies, ventricular septal defect, patent ductus arteriosus, tetralogy of Fallot, atrial septal defect, right-sided aortic arch, genitourinary anomalies, renal agenesis, renal dysphagia, horseshoe kidney, polycystic kidney, ureteral malformation, urethral malformation, hypospadia, gastrointestinal anomalies, imperforate anus, duodenal atresia, malrotation, intestinal malformation, Meckel diverticulum, annular pancreas, musculoskeletal anomalies, hemivertebrae, radial dysphagia, radial amelia, polydactyly, syndactyly, rib malformation, scoliosis, lower limb defect, tracheomalacia, esophageal dysmotility, gastroesophageal reflux, pharyngeal pseudodiverticulum, Zenker diverticulum, esophagoscopy

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St. Boniface General Hospital
Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Donald Duerksen, MD, Assistant Professor, Department of Medicine, Section of Gastroenterology, University of Manitoba, Canada
Donald Duerksen, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society for Parenteral and Enteral Nutrition
Disclosure: Nothing to disclose.

Medical Editor

Marco Patti, MD, Director, Center for the Study of Gastrointestinal Motility and Secretion, Moffitt-Long Hospital; Associate Professor, Department of Surgery, University of California at San Francisco
Marco Patti, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Surgical Association, Association for Academic Surgery, Pan-Pacific Surgical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Southwestern Surgical Congress, and Western Surgical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Noel Williams, MD, Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.