Page 11 of 73 GULLET DISEASES
Atresia and esophageal and tracheal fistula
The atresia of a gullet is observed at 1 of 3000 — 4500 newborns; in every third case such child is premature. More than in 75% of cases of an atresia fistula between distal department of a gullet and a trachea accompanies (fig. 12-4, a). Development only by one of these anomalies is possible. Believe that disturbance of process of a differentiation at a stage of separation of a trachea from a gullet is their cornerstone; the wrong growth of entodermalny cells conducts to an atresia, and incomplete merge of sidewalls of an intestinal tube is the reason of burrowing, usually at the level of bifurcation of a trachea. In a pathogeny of this defect genetic factors do not play an essential role.
Clinical manifestations. It is necessary to think of an atresia of a gullet if: a) the hydramnion took place, b) the catheter used for suction does not manage to be entered into the newborn's stomach, c) plentiful allocations from a mouth and the child's throat are observed, d) in feeding attempt the child poperkhivatsya, begins to cough, becomes cyanochroic.
Fig. 12-4. The schematic image of 5 most widespread options of a ratio between an atresia of a gullet and esophageal and tracheal fistula in the order corresponding to prevalence.
Unfortunately, the diagnosis is often made only after attempt to feed the child; suction of liquid from an oral cavity and a throat often leads to improvement of a state, however symptoms soon appear again. Because the distal department of a gullet is often connected by fistula to a trachea, the stomach is blown usually up to such an extent that complicates breath. If fistula is between a trachea and proximal department of a gullet, then already the first attempt to feed the child leads to aspiration of a large amount of milk. At children with an atresia, but without fistula, the stomach is pulled in and does not contain gases. In those exceptional cases when there is fistula, but there is no atresia (fig. 12-4, c), recurrent aspiration pneumonia becomes the main display of an illness, and the correct diagnosis is established sometimes only in several days or even months. Aspiration of secrets of a throat — almost constant phenomenon at patients with a gullet atresia, however is much more dangerous hit in lungs of gastric contents through distal fistula as it causes a heavy life-threatening pneumonitis.
Approximately at 30% of patients with an atresia of a gullet also other congenital anomalies are observed, many of which in itself threaten the child's life. Among them defects of cardiovascular system are most frequent; except them malformations of a digestive tract, uric ways, a backbone in central a nervous system meet.
Diagnosis. The diagnosis has to be established as soon as possible, it is desirable right after the child's birth as aspiration of milk is the major factor defining the Forecast. At suspicion on an atresia the diagnosis is confirmed by impossibility to enter a catheter into a stomach. Usually the catheter stops at distance of 10 — 11 cm from gums and is curtailed in a breast blind esophageal pocket that is visible on the roentgenogram (fig. 12-5). Besides, a typical radiological sign is gullet stretching air. Availability of air in a stomach indicates the message of a trachea with distal department of a gullet.
Fig. 12-5. The roentgenogram of the newborn with gullet fistula. The curtailed catheter outlines contours of a breast sleny pocket. Availability of air in an abdominal cavity indicates existence of fistula between a trachea and distal department of a gullet.
It is necessary to apply water-soluble substances to contrasting; to reveal a blind breast pocket, it is enough to enter less than 1 ml of substance under roentgenoscopic control. After research it needs to be removed to warn an aspiration chemical pneumonitis. In cases when there is fistula, but there are no atresias, so-called N-type (fig. 12-4, c) the diagnosis is made by method of X-ray cinematography of the contrasted gullet. From a trachea the fistular opening can be found easily at a bronkhoskopiya.
Treatment. The atresia of a gullet demands urgent surgical intervention. The child has to be in the preoperative period facedown to prevent throwing of contents of a gullet in lungs. Contents of a breast esophageal pocket need to be sucked away constantly. It is important to watch the body temperature and breath. By means of the bronchoscope resort to aspiration both in preoperative, and in postoperative the periods with the purpose to avoid development of atelectases. The accompanying inborn malformations are the frequent reason of a lethal outcome. Sometimes the condition of the patient forces to operate step by step. The first stage — closing of fistula and creation of a gastrostomy for feeding; the second - anastomozirovapy two pieces of a gullet. In 8 — 10 days after imposing of an anastomosis it is possible to begin to feed the child in the natural way. Full value of an anastomosis is established radiological. Often there is its stenosis in this connection carry out dilatation". Motive function of distal part of a gullet after operation is always broken that leads to emergence of a gastroesophagal reflux, aspiration, an esophagitis and formation of a stricture (see. Gastroesophagal reflux).