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Mind the gap: delayed diagnosis of oesophageal atresia and tracheo-oesophageal fistula due to passage of a nasogastric tube
  1. Giampiero Soccorso,
  2. Richard J England,
  3. Prasad P Godbole,
  4. Ross M Fisher,
  5. Sean S Marven
  1. Paediatric Surgical Unit, Sheffield Children's NHS Foundation Trust, Sheffield, UK
  1. Correspondence to G Soccorso, Paediatric Surgical Unit, Sheffield Children Hospital NHS Trust, Western bank, Sheffield, South Yorkshire S10 2TH, UK; giampsoccorso{at}

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Two neonates developed sialorrhoea and feeds intolerance. A nasogastric tube (NGT) was passed with difficulty and its gastric position confirmed radiologically in both (figure 1A,B). Oesophageal atresia with tracheo-oesophageal fistula (OA/TOF) was therefore ‘excluded’. However, the babies continued to chock with feeds.

Figure 1

(A, B) In both babies the babygram showed the ‘correct’ position of the nasogastric tube, with the tip lying in the stomach.

A second attempt at inserting a NGT was unsuccessful and further radiographs showed coiled tubes in the upper oesophagus. The oesophageal continuity was tested with a 10 Fr Replogle tube which stopped at about 10 cm from the nostril. Contrast radiographs with the Replogle in place made the diagnosis of OA/TOF in both neonates (figure 2) and confirmed at surgery.

Figure 2

The contrast instilled via the Replogle tube outlined a blind-ending upper oesophageal pouch extending to just below the thoracic inlet. A similar picture was seen in the other baby.


Newborns with OA/TOF can tolerate a small NGT that passes through the larynx, the trachea, the fistula/distal oesophagus and reaches the stomach.1,,3

‘Successful’ passage of the NGT is often defined by the length of tube inserted and a pH test, but neither test can exclude passage to the stomach by an abnormal route. An antero-posterior film might highlight a minor deviation from the midline4; a lateral chest x-ray is not routinely indicated. If a baby remains symptomatic in spite of ‘successful’ passage of a NGT, the possibility of OA/TOF should still be considered, a further attempt at passage of a stiff 10 Fr catheter should be undertaken and, where doubt persists, a contrast radiograph should be performed by an experienced radiologist.5


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  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.