675

Because of premature labor and a breech presentation, a 1,2009 white boy, a first-born
Stomach Rupture
Associated with Esophageal
Atresia, Tracheoesophageal
Fistula, and Ventilatory
Assistance
Thomas B. Jones1
Sandra G. Kirchner1
Fred A. Lee2
Richard M. Heller1
W hen infants with tracheoesophageal fistula require ventilatory assistance, gastric
distention may ultimately result in perforation and pneumoperltoneum. This report
describes four neonates with esophageal atresla and tracheoesophageal fistula who
experienced such a complication.
Perforation of the gastrointestinal tract and pneumoperitoneum can result from
ventilatory assistance in a newborn with an anatomically normal gastrointestinal
tract [1 , 2]. Therefore, it is not surprising that ventilatory assistance in a newborn
with esophageal atresia and distal tracheoesophageal fistula might lead to
marked gastric distention, especially in the presence of duodenal atresia [3].
Gastric rupture in a newborn with a tracheoesophageal fistula has also been
reported [4, 5]. W e report four additional cases that emphasize the necessity of
considering tracheoesophageal fistula when a newborn receiving ventilatory
assistance develops marked gastric distention or a pneumoperitoneum.
Case Reports
Case 1
Received July 17, 1979; accepted after revi-
sion December 12, 1979.
Department of Radiology and Radiological Sci-
ences, vanderbilt University Medical Center,
Nashville, TN 37232. Address reprint requests to
T. B. Jones.
2Department of Radiology, Childrens Hospital
of Los Angeles, University of Southern California
School of Medicine, Los Angeles, CA 90033.
AJR 134:675-677, April 1980
0361 -8o3x/8o/1 344-0675 $00.00
American Roentgen Ray Society
A 1 .600 9 white boy was delivered at 35 weeks gestation due to premature labor.
Ultrasound examination 1 month before delivery revealed hydramnios. After delivery, Apgar
scores were 2 at 1 mm and 1 at 5 mm, necessitating intubation in the delivery room. An
initial radiograph showed hyaline membrane disease and an orogastric tube ending in the
upper esophagus. The stomach and proximal duodenum were distended with air (double
bubble) without any distal small bowel gas (fig. 1 A). Abdominal distention increased and a
subsequent radiograph revealed a pneumoperitoneum (fig. I B). The diagnosis of esopha-
geal atresia, tracheoesophageal fistula, duodenal atresia, and gastric rupture was made.
At laparotomy a large perforation along the lesser curvature was repaired and a gastrostomy
tube inserted. The infants condition precluded more extensive surgery. Postoperatively
the patient developed massive intraperitoneal bleeding and expired.
Case 2
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Fig. 1.-Case 1. A, Anteroposterior radiographs of chest and abdomen. A, Orogastric tube with tip
in upper esophagus. Endotracheal tube and umbilical venous catheter also seen. Pulmonary parenchy-
mal pattern consistent with hyaline membrane disease; abdominal bowel gas pattern suggests duodenal
obstruction. B, 8 hr later. Large pneumoperitoneum now seen.
Fig. 2.-Case 2. Anteroposterior radiograph of
chest and abdomen. Gas distends stomach and fills
large and small bowel. Large pneumoperitoneum;
diffuse pulmonary infiltrates. Endotracheal tube and
umbilical arterial catheter.
676 JONES ET AL. AJR:134, April 1980
4
I
twin, was delivered by cesarean section at 33 weeks gestation. He
had Apgar scores of 4 at 1 mm and 5 at 5 mm, necessitating
intubation in the delivery room. After several hours he developed
progressive abdominal distention and radiographs revealed a
greatly distended stomach with some small bowel gas. Subsequent
radiographs revealed a pneumoperitoneum (fig. 2). An orogastric
tube would not pass into the stomach. The diagnosis of esophageal
atresia, tracheoesophageal fistula, and gastric rupture was made.
At surgery, a gastric rupture along the lesser curvature was repaired
and a gastrostomy tube placed. The infant developed respiratory
distress syndrome, a patent ductus arteriosus, and expired after a
massive intraventricular hemorrhage.
Case 3
A 1 .250 9 white male boy, a second-born twin (brother of case
2), was also delivered by cesarean section. His Apgar scores were
1 at 1 mm and 7 at 5 mm, necessitating intubation in the delivery
room. He had increasing abdominal distention and an orogastric
tube could not be passed. Radiographs showed the orogastric tube,
ending in the proximal esophagus, and a pneumoperitoneum. At
surgery, a gastric perforation along the lesser curvature was re-
paired and a gastrostomy tube inserted. Postoperatively the infant
developed intraabdominal bleeding, shock, and respiratory failure,
and he subsequently expired.
Case 4
A 1,2199 white girl was delivered at 31 weeks gestation because
of premature labor. She developed respiratory distress syndrome
and was placed on ventilatory assistance. Her abdomen became
markedly distended and an orogastric tube could not be passed.
Radiographs revealed a pneumoperitoneum. A large gastric perfo-
ration along the lesser curvature was repaired at surgery and a
gastrostomy tube inserted. The tracheoesophageal fistula was Ii-
gated. The infant had a difficult course with respiratory distress
syndrome, sepsis, and seizures. At age 3 months, she required a
tracheostomy due to laryngomalacia, subglottic and supraglottic
stenosis, and left vocal cord paralysis, but she has survived.
Discussion
Of the five types of esophageal atresia and tracheoesoph-
ageal fistula, esophageal atresia with a fistula between the
trachea and the distal esophageal pouch is the most corn-
rnon, constituting over 80% of all cases and including all
four of our cases. W hen these infants require intubation and
ventiiatory assistance, the increased pressure in the airway
has a direct route to the gastrointestinal tract via the trache-
oesophageal fistula. W hile the development of a pneumo-
peritoneum may result from dissection of a pneumomedias-
tinum [6], perforation of the gastrointestinal tract with its
associated high mortality must be excluded [7, 8].
The work of Heller et al. [9] suggests that a combination
of increased pressure and immature muscular development
predisposes to gastric rupture. All four of our patients were
premature and had elevated gastric pressures secondary to
artificial ventilation and tracheoesophageal fistulas. The as-
sociated duodenal atresia in case 1 very likely resulted in
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AJR:134, April 1980 STOMACH RUPTURE W ITH ASSISTED VENTILATION 677
even greater gastric intraluminal pressure. In all four cases,
the gastric rupture was along the lesser curvature, as is
often the case with rupture secondary to overdistention.
Spontaneous rupture of the stomach can also occur, usually
within a few days after birth. It has been reported that such
perforations occur along the greater curvature [10]. W hen
an infant receiving ventilatory assistance develops severe
gastric distention or pneumoperitoneum, tracheoesopha-
geal fistula with or without esophageal atresia must be
considered.
ACKNOWLEDGMENTS
W e thank Betty Burnside for help in manuscript preparation and
Yukio Hirata for help in translation.
REFERENCES
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ventilator therapy in respiratory distress syndrome. Am J Dis
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3. McCook TA, Felman AH. Esophageal atresia, duodenal atresia,
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