Systemic glucocorticoids can decrease symptoms, but longterm use is discouraged secondary to complications. Swallowed “topical” glucocorticoids administered via a metered dose inhaler (fluticasone) or mixed as a slurry (budesonide)
Esophageal atresia Esophageal atresia H-type TEF with distal TEF with no TEF (4%) (85%) (8%)
Esophageal atresia Esophageal atresia with with proximal TEF proximal and distal TEF Figure 128-3 Various types of tracheoesophageal fis have shown benefit. Candida esophagitis or oral thrush are the most common side effects.
Endoscopy can be used to relieve food impactions and to dilate esophageal strictures secondary to EoE. The prognosis for EoE is largely unknown. Symptoms tend to wax and wane over time.
Failure to thrive or weight loss may be seen due to difficulty in eating. Food impactions are a common complication in the older child and may require endoscopic removal. Chronic inflammation of the esophagus can predispose to esophageal strictures and possibly dysplasia.
The esophagus and trachea develop in close proximity to each other during weeks 4 to 6 of fetal life. Defects in the mesenchyme separating these two structures result in a tracheoesophageal fistula (TEF), often in association with other anomalies (renal, heart, spine, limbs). This defect occurs in about 1 in 3000 live births. TEF is not thought to be a genetic defect.
The most common forms of TEF occur with esophageal atresia; the “H-type” TEF without atresia is uncommon, as is esophageal atresia without TEF (Fig. 128-3). Associated defects include the VACTERL association—vertebral anomalies (70%), anal atresia (imperforate anus) (50%), cardiac anomalies (30%), TEF (70%), renal anomalies (50%), and limb anomalies (polydactyly, forearm defects, absent thumbs, tulas (TEF) with relative frequency (%).
syndactyly) (70%). A single-artery umbilical cord is often present. Infants with esophageal atresia have a history of polyhydramnios, exhibit drooling, and have mucus and saliva bubbling from the nose and mouth. Patients with a TEF are vulnerable to aspiration pneumonia. When TEF is suspected, the first feeding should be delayed until a diagnostic study is performed.
The simplest test for TEF is to gently attempt to place a 10For larger tube via the mouth into the stomach. The passageof the tube is blocked at the level of the atresia. A chest x-rayreveals the tube coiled in the esophageal pouch. Air can beinjected through the tube to outline the atretic pouch. Barium should not be used because of extreme risk of aspiration,but a tiny amount of dilute water-soluble contrast agent canbe given carefully, then aspirated when the defect is clearlyshown.
The treatment of TEF is surgical. The fistula is divided and ligated. The esophageal ends are approximated and anastomosed. In some cases, primary anastomosis cannot be performed because of a long gap between the proximal and distal esophagus. Various techniques have been described to treat this problem, including pulling up the stomach, elongating the esophagus by myotomy, and simply delaying esophageal anastomosis and providing continuous suction to the upper pouch while allowing for growth.
The surgically reconstructed esophagus is not normal and is proneto poor motility, GER, anastomotic stricture, recurrent fistula, and leakage. The trachea also is malformed; tracheomalacia and wheezing are common.