A nasogastric tube coiled in a blind upper pouch on the chest radiograph; gas in the stomach means a distal fistula (the common type), a gasless abdomen means pure atresia — then look for VACTERL anomalies.
Orient first
- Presents with drooling, choking on feeds and inability to pass a tube; polyhydramnios antenatally.
- Gross type C (proximal atresia with distal fistula) is the commonest.
- VACTERL: vertebral, anorectal, cardiac, TEF, renal, limb anomalies; a right-sided aortic arch changes the surgical approach.
Acquire the study
- Chest and abdomen radiograph with a radio-opaque tube passed gently until it stops; contrast pouch studies only in specialist centres.
The manoeuvre
- Tube tip: coiled in the upper pouch at the level of the second to fourth thoracic vertebrae.
- Abdomen: gas in the stomach and bowel (distal fistula) vs gasless (pure atresia or proximal fistula only).
- Vertebrae and ribs: segmentation anomalies.
- Heart and aortic arch side (to the side of the trachea indentation).
- Lungs: aspiration pneumonia in the right upper lobe.
What confirms it
- A tube arrested in a blind upper pouch, with the abdominal gas pattern defining the type.
What licenses you to exclude it
- A tube passing freely into the stomach excludes atresia; it does not exclude an H-type fistula.
The classic misread
- A stiff tube kinking in a normal oesophagus mimics a pouch.
- Missing the H-type fistula, which needs a prone pull-back oesophagram.