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Tracheoesophageal Fistula Workup

  • Author: Sat Sharma, MD, FRCPC; Chief Editor: Julian Katz, MD  more...
Updated: Jan 03, 2016

Imaging Studies

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  • 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).


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  • 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.
Contributor Information and Disclosures

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, World Medical Association

Disclosure: Nothing to disclose.


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, American Society for Parenteral and Enteral Nutrition

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Noel Williams, MD, FRCPC FACP, MACG, 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, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

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 & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Marco G Patti, MD Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine

Marco G Patti, MD is a member of the following medical societies: American Association for the Advancement of Science, American Surgical Association, American College of Surgeons, American Gastroenterological Association, American Medical 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, Western Surgical Association

Disclosure: Nothing to disclose.

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Tracheoesophageal fistula. During development of respiratory and digestive systems, a single primitive tube develops lung bud and tracheoesophageal septum forms by 4-6 weeks of gestational age. The septum separates the foregut and tracheobronchial tree by 6 weeks of gestational age.
Tracheoesophageal fistula. The cuff of endobronchial causes circumferential ischemia and injury to the trachea; the erosion leads to formation of tracheoesophageal fistula.
Tracheoesophageal fistula. H-type of tracheoesophageal fistula.
Tracheoesophageal fistula. Esophageal atresia with distal tracheoesophageal fistula.
Tracheoesophageal fistula. Isolated esophageal atresia without tracheoesophageal fistula.
Table. Classification of Congenital Tracheoesophageal Fistulas and Esophageal Atresia
Anatomic Characteristics Percent of Cases
Esophageal atresia with distal TEF87
Isolated esophageal atresia without TEF8
Isolated TEF4
Esophageal atresia with proximal TEF1
Esophageal atresia with proximal and distal TEF1
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