Share this article on:

Delayed Identification of Proximal Tracheoesophageal Fistula

Chiou, Eric*; Ongkasuwan, Julina

Journal of Pediatric Gastroenterology and Nutrition: May 2014 - Volume 58 - Issue 5 - p e45
doi: 10.1097/MPG.0b013e31826a102c
Image of the Month

*Texas Children's Hospital Aerodigestive Program, Baylor College of Medicine, Houston

Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston.

Address correspondence and reprint requests to Eric Chiou, MD, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital Aerodigestive Program, Baylor College of Medicine, 6701 Fannin St, CCC 1010.00, Houston, TX 77030 (e-mail:

Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

The authors report no conflicts of interest.

A 15-year-old girl with the history of trisomy 21 and isolated esophageal atresia (EA) status postrepair in infancy was referred for evaluation of chronic aspiration suggested by the incidental finding of diffuse bronchiectasis on chest computed tomography (Fig. 1). Subsequent upper gastrointestinal series with contrast did not show evidence of a tracheoesophageal fistula (TEF), and modified barium swallow study was also negative for aspiration. The patient underwent combined esophagogastroduodenoscopy and direct laryngobronchoscopy. A previously undetected proximal TEF was identified (Fig. 2).





TEF is a relatively common congenital anomaly, occurring approximately 1 in 3500 live births, with the majority of cases occurring in conjunction with EA (1). Association with other congenital anomalies, such as VACTERL (vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb anomalies) association, is also frequent (2). TEF and EA usually present with polyhydramnios prenatally, or in the immediate postnatal period with excessive secretions, respiratory distress, and inability to feed. Diagnosis of proximal TEFs can be challenging, however, and even delayed into adulthood (3). Depending on the size of the fistula, they may have minimal symptoms and can be missed on contrast radiography or at the time of EA repair (4). In these cases, esophageal endoscopy and bronchoscopy should be performed to evaluate for TEF if the clinical suspicion is high. After the proximal TEF was identified in the present case, the fistula tract was de-epithelialized with a Bugbee fulgurating electrode and then sealed with fibrin glue under endoscopic guidance.

Back to Top | Article Outline


1. Depaepe A, Dolk H, Lechat MF. The epidemiology of tracheo-oesophageal fistula and oesophageal atresia in Europe. EUROCAT Working Group. Arch Dis Child 1993; 68:743.
2. Keckler SJ, St Peter SD, Valusek PA, et al. VACTERL anomalies in patients with esophageal atresia: an updated delineation of the spectrum and review of the literature. Pediatr Surg Int 2007; 23:309.
3. Zacharias J, Genc O, Goldstraw P. Congenital tracheoesophageal fistulas presenting in adults: presentation of two cases and a synopsis of the literature. J Thorac Cardiovasc Surg 2004; 128:316.
4. Bax KN, Roskott AM, van der Zee DC. Esophageal atresia without distal tracheoesophageal fistula: high incidence of proximal fistula. J Pediatr Surg 2008; 43:522–525.
© 2014 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,