Small/Absent Stomach
Paula J. Woodward, MD
DIFFERENTIAL DIAGNOSIS
Common
Normal Transient Finding
Esophageal Atresia
Congenital Diaphragmatic Hernia
Oligohydramnios
Less Common
Abnormal Swallowing
Arthrogryposis, Akinesia Sequence
Cleft Lip, Palate
Rare but Important
Neck Mass
Goiter
Teratoma
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
Often difficult to define when a stomach is “small”
No defined measurements
Stomach size varies between patients
Stomach size varies in same fetus over several hours
Related to swallowing and peristalsis
Requires experience
More likely to be a true finding if polyhydramnios is present
Helpful Clues for Common Diagnoses
Normal Transient Finding
1% of normal fetuses have a small or absent stomach on initial scan, especially in 1st and 2nd trimester
Always get a follow-up exam if there is any question
Esophageal Atresia
Atresia of esophagus often associated with tracheoesophageal fistula (TEF)
> 90% have a fistula
Proximal atresia with distal TEF most common type
Small or absent stomach
Complete absence suggests either no TEF or a very small, stenotic connection
Presence of fistula allows a small amount of fluid to enter stomach via the trachea
Look for esophageal “pouch” sign
Transient filling of proximal esophagus with swallowing
Best performed in a coronal plane
Use color Doppler to identify carotid and jugular vessels
IUGR seen in up to 40%
Ingested amniotic fluid important for growth in latter half of gestation
Polyhydramnios rarely develops before 20 weeks
Fetal swallowing not important part of amniotic fluid dynamics until that time
Polyhydramnios usually progressive after 20 weeks and may be severe in 3rd trimester
Part of VACTERL association
Vertebral anomalies
Anal atresia
Cardiac malformation
Tracheoesophageal fistula
Renal anomalies
Limb malformation (frequently radial ray)
Also associated with aneuploidy
Trisomy 18 > trisomy 21
Congenital Diaphragmatic Hernia
Stomach in chest rather than normal location
May also have small bowel and liver in chest
Peristalsis within chest mass is pathognomonic
Abdominal circumference small
Polyhydramnios common
Oligohydramnios
Stomach is normal but may not be visible because of lack of fluid to swallow
Stomach usually seen unless oligohydramnios is severe
Renal agenesis
Bilateral multicystic dysplastic kidneys
Severe autosomal recessive polycystic kidney disease
Posterior urethral valves
Helpful Clues for Less Common Diagnoses
Arthrogryposis, Akinesia Sequence
Refers to a symptom complex caused by multiple different etiologies, resulting in lack of fetal movement
Also includes lack of facial movement
Open mouth posture
Recessed chin
Decreased fetal swallowing
Unusual or persistent abnormal posturing of limbs
Persistent “pike” position of lower limbs with hyperextended knees
Cross-legged “tailor’s position” of lower limbs, especially in a breech fetus
Clubfeet, may be very severe
Clenched hands that never open
Cleft Lip, Palate
Significant clefts may cause impaired swallowing
80% with cleft lip (CL) will also have cleft palate (CP)
Classification
Type 1: Unilateral CL without CP
Type 2: Unilateral CL with CP
Type 3: Bilateral CL/CP
Type 4: Midline CL/CP
Type 3-4 CL/CP often associated with aneuploidy/syndromes
Also more likely to have impaired swallowing
Helpful Clues for Rare Diagnoses
Goiter
Homogeneous, smooth, anterior neck mass
Maintains thyroid contour
Similar appearance to a normal adult thyroid
May obstruct swallowing resulting in polyhydramnios and small stomach
If esophagus is obstructed, trachea is also likely compressed
May cause airway compromise at birth
May prevent normal fetal “chin tuck” → extended neck → obstructed labor
Teratoma
Mixed echogenicity mass with cystic and solid components
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