A Rare Association of Congenital Diaphragmatic Hernia with Lower Esophageal Atresia and Perforation

Congenital diaphragmatic hernia is known to be associated with esophageal atresia, which is a rare association. We report a rare occurrence of congenital diaphragmatic hernia and lower esophageal atresia. 1. Introduction Abnormalities of the esophagus such as gastroesophageal reflux disease (GERD), esophageal motility disorders, esophageal duplications cysts, and tracheoesophageal fistula with esophageal atresia are rare but documented occurrences with congenital diaphragmatic hernia [1, 2]. We report a rare association of lower esophageal atresia with congenital diaphragmatic hernia (CDH). 2. Case Report A 10-day male child presented with respiratory distress without cyanosis since birth. On clinical examination, patient had tachypnea, with a scaphoid abdomen. The persistent drooling of saliva led to the suspicion of esophageal atresia. A red rubber catheter was passed into the esophagus, but there was resistance at 15？cm from the alveolar margin. Chest X-ray showed evidence of left CDH with mediastinal shift and the tip of nasogastric tube at the level of the diaphragm. A contrast esophagogram was done which showed holdup of dye at the level of the diaphragm (Figure 1). With the suspicion of associated esophageal obstruction and CDH, a laparotomy was done using a chevron incision. The operative findings include left posterolateral CDH, complete disruption of the esophagogastric junction with a blind-ending esophagus, and a sealed esophageal perforation at the esophagogastric junction (Figure 2). Figure 1: Contrast esophagogram showing holding up (arrow) of contrast at the level of the diaphragm with evidence of CDH with lower esophageal obstruction. Figure 2: Operative photograph showing a blind ending of the lower esophagus with a sealed perforation (arrow). The surgical correction included repair of CDH and esophagogastric anastomosis with a feeding jejunostomy. The postoperative course was uneventful. Jejunostomy feeds were started on the 4th postoperative day. Contrast esophagogram was done on the 10th postoperative day. It showed free flow of dye into the stomach. At discharge, the child was on full oral feeds. He has been followed up for 3 months. The child’s general condition is good with adequate weight gain. 3. Discussion Esophageal anomalies are known to be associated with CDH. These associations include tracheoesophageal fistula with esophageal atresia, GERD, esophageal dysmotility, esophageal duplication cysts, and esophageal ectasia [1, 2]. The possible noted explanations include the kinking of the esophagogastric junction [2] and