A 3-day-old, term baby boy presents with choking, coughing and persistent drooling of frothy saliva. He has cyanotic spells during attempted feeds. A nasogastric tube cannot be advanced beyond about 12 cm. A chest and abdominal X-ray shows the coiled tube in the upper chest and gas present in the bowel below the diaphragm. What is the most likely diagnosis?

Answer: B. Oesophageal atresia with a distal tracheo-oesophageal fistula

Oesophageal atresia and tracheo-oesophageal fistula (TOF)

Oesophageal atresia results from failure of the primitive foregut tube to separate correctly into the oesophagus and trachea. The classic neonate presents with drooling of saliva, choking, coughing, respiratory distress and cyanotic spells after feeds, with an inability to pass a nasogastric tube beyond 10-15 cm.

Reading the X-ray

• A coiled NG tube in the upper oesophageal pouch confirms atresia.
• Gas in the bowel below the diaphragm indicates a distal TOF (air reaches the gut through the fistula) - the commonest variant (type C).
• A gasless abdomen instead would indicate pure atresia with no distal fistula.

Associations - VACTERL (around 50%)

• Vertebral, Anorectal (anal atresia), Cardiac (VSD, PDA), Tracheo-oesophageal, Esophageal, Renal (agenesis), Limb.
• Antenatal clues: polyhydramnios (failure to swallow amniotic fluid), small or absent stomach bubble, dilated upper oesophagus.

Initial management

1. Nil by mouth; continuous suction of the upper pouch (Replogle tube) to prevent aspiration.
2. IV fluids, oxygen, head-up positioning to reduce reflux through the TOF.
3. Screen for associations: 2D echo, renal ultrasound, spine X-ray, chromosomes.
4. Definitive surgery: thoracotomy with division of the TOF and oesophageal anastomosis.

Post-operative complications

• Anastomotic leak, oesophageal stricture, recurrent fistula, gastro-oesophageal reflux.