Severe upper gastrointestinal hemorrhage from linear gastric ulcers in large hiatal hernias: a large prospective case series of Cameron ulcers

A Case of Cameron Lesions: An Overlooked Cause of Anemia in Patients With Gastrointestinal Bleeding and Hiatal Hernia

Cameron lesions are rare causes of upper gastrointestinal bleeding (UGIB). The lesions are linear erosions or ulcers that develop in the sac of a hiatal hernia, which often go unnoticed in the upper gastrointestinal system, and are a prevalent cause of anemia resulting from iron deficiency. Postponed treatment can result in severe consequences such as potentially fatal hemorrhaging. Here, we present a case of a young woman who presented to the emergency room with recurrent gastrointestinal bleeding and severe microcytic anemia. The chest X-ray revealed a partial intrathoracic stomach, and a large hiatal hernia was subsequently confirmed in the CT scan of the abdomen and pelvis. The esophagogastroduodenal endoscopy indicated Los Angeles Classification System grade A reflux esophagitis and an 8 cm hiatal hernia with multiple Cameron ulcers with pigmented material and chronic non-erosive gastritis. Biopsies of the gastric body and antrum showed Helicobacter pylori-associated chronic active gastritis and intestinal metaplasia. An esophagus biopsy showed squamous esophageal mucosa with mild chronic inflammation. The patient was treated with a transfusion of three units of red blood cells, iron replenishment, and pantoprazole infusion and underwent hiatal hernia repair with mesh and Toupet fundoplication without any complications. After that, the patient was discharged and scheduled for follow-up with general surgery at the outpatient clinic.

Rare causes of acute non-variceal upper gastrointestinal bleeding: A comprehensive review

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common gastroenterological emergency associated with significant morbidity and mortality. Gastroenterologists and other involved clinicians are generally assisted by international guidelines in its management. However, NVUGIB due to peptic ulcer disease only is mainly addressed by current guidelines, with upper gastrointestinal endoscopy being recommended as the gold standard modality for both diagnosis and treatment. Conversely, the management of rare and extraordinary rare causes of NVUGIB is not covered by current guidelines. Given they are frequently life-threatening conditions, all the involved clinicians, that is emergency physicians, diagnostic and interventional radiologists, surgeons, in addition obviously to gastroenterologists, should be aware of and familiar with their management. Indeed, they typically require a prompt diagnosis and treatment, engaging a dedicated, patient-tailored, multidisciplinary team approach. The aim of our review was to extensively summarize the current evidence with regard to the management of rare and extraordinary rare causes of NVUGIB.

Changes in Hemoglobin Levels in Patients with Hiatal Hernia and Anemia Demonstrates a Durable Resolution When Surgery Utilized

Objective:

To describe the patterns of care of patients presenting with anemia and a hiatal hernia and to document hemoglobin levels at each stage of care.

Background data:

Anemia may be associated with hiatal hernia. Current medical guidelines recommend iron supplements and proton pump inhibitors (PPIs) as initial steps, but not surgical repair is not routinely recommended despite evidence of cure.

Methods:

Retrospective review of patients with anemia and hiatal hernia who underwent surgical repair. Hemoglobin, PPI use, and symptoms were assessed at diagnosis, preoperatively, and postoperatively.

Results:

We identified 116 predominantly female patients with type 3 hernias with 52.6% (n = 61) having Cameron ulcers. At baseline, 24.1% (n = 28) were transfused, 52% (n = 60) started on iron supplements, 72% (n = 84) on PPIs, and 10% (n = 12) on H2-blockers. Referral to surgery occurred 454 days (IQR: 129-1332) after anemia diagnosis. The mean Hgb at diagnosis was 9.79 (range: 4.8-12.7) in females and 10.9 (range: 7.7-12.9) in males, increasing to 11.1 (range: 5.4-15) and 11.4 (range: 5.8-15.9) with medical management. After laparoscopic repair, it increased to 12.3 (range: 8.1-14.8) and 13.4 (range: 8.9-16.8) at short term follow up. This was sustained at 12.8 (range: 8.8-17.7) and 14.2 (8.1-17) long term. Medical management normalized Hgb in 36% (n = 40/111); whereas surgery normalized Hgb in 62% (n = 64/104) short term and 74% (n = 69/93) long term. Cameron’s ulcers were associated with normalization in 85% (38/45) but only 62% (n = 21/34) when not present.

Conclusion:

Anemia associated with a hiatal hernia improves with medication, but the addition of surgery normalizes Hgb, appears durable, allows cessation of medication, and improves quality of life.

Overt GI bleeding from a Cameron lesion in an Ethiopian with NSAID use: Case report of an unusual condition

Introduction

Cameron Lesions are linear breaks in the proximal gastric mucosa, mostly in association with hiatal hernia. The condition presents with chronic iron deficiency anemia and occasionally with obscure bleeding. Overt bleeding is very rare and has not been reported in sub- Saharan Africa context.

Case

A 78 year old male patient, with an already diagnosed hiatal hernia and gouty arthritis, presented with massive upper GI bleeding requiring resuscitation and blood transfusion. The patient was taking indomethacin for a gout flare prior to the episode and clinical suspicion was a peptic ulcer disease as the culprit for the bleeding. Endoscopy was done and it showed two linear erosions with recent bleeding in the hernia sac. No other bleeding source was identified. The patient was treated with a Proton Pump Inhibitor (PPI).

Discussion

Cameron lesions could present with massive bleeding and should be actively looked for in patients with hiatal hernia as they could be easily missed. Even with concurrent NSAID use, the condition could be a cause of major bleeding and careful evaluation is important. Management entails PPI therapy with occasional endoscopic intervention.

Conclusion

In the setting of hiatal hernia, Cameron lesions should be actively looked for in patients presenting with overt GI bleeding.

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Cameron lesions are linear breaks in the proximal gastric mucosa in the setting of hiatal hernia.

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Usually these lesions present with chronic iron deficiency anemia.

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Overt bleeding from Cameron lesions is rare and has not been well described in Sub-Saharan Africa.

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Despite the use of NSAIDs, these lesions could be an alternative cause of major GI bleeding and should be actively sought.

Cameron lesion with severe iron deficiency anemia and review of literature

Background

Iron deficiency is the most common cause of anemia in many developing countries including India. Inadequate iron in diet, poor iron absorption, excessive bleeding, or chronic blood loss in the stool/ urine may be the cause. Cameron lesions are mucosa injuries of gastric body or fundus in the background of hiatal hernia.

Case Presentation

Here we describe a case report of a 50-year-old female who presented to hospital with pain in abdomen. During laboratory workup she had severe anemia due to iron deficiency. Esophagogastroduodenoscopy revealed a large hiatal hernia with a superficial ulcer present in the hiatal pouch, the GE junction being 35 cm from the incisors. So, a hiatus hernia with a Cameron ulcer was identified as the culprit of iron deficiency anemia.

Conclusion

The diagnosis of a Cameron lesion is difficult and sometimes ignored. In patients with anemia/bleeding, thorough surveillance of all stomach folds is essential, especially if a significant hiatal hernia is present.

Gastrointestinal Bleeding at CT Angiography and CT Enterography: Imaging Atlas and Glossary of Terms

Gastrointestinal (GI) bleeding is a common potentially life-threatening medical condition frequently requiring multidisciplinary collaboration to reach the proper diagnosis and guide management. GI bleeding can be overt (eg, visible hemorrhage such as hematemesis, hematochezia, or melena) or occult (eg, positive fecal occult blood test or iron deficiency anemia). Upper GI bleeding, which originates proximal to the ligament of Treitz, is more common than lower GI bleeding, which arises distal to the ligament of Treitz. Small bowel bleeding accounts for 5-10% of GI bleeding cases commonly manifesting as obscure GI bleeding, where the source remains unknown after complete GI tract endoscopic and imaging evaluation. CT can aid in identifying the location and cause of bleeding and is an important complementary tool to endoscopy, nuclear medicine, and angiography in evaluating patients with GI bleeding. For radiologists, interpreting CT scans in patients with GI bleeding can be challenging owing to the large number of images and the diverse potential causes of bleeding. The purpose of this pictorial review by the Society of Abdominal Radiology GI Bleeding Disease-Focused Panel is to provide a practical resource for radiologists interpreting GI bleeding CT studies that reviews the proper GI bleeding terminology, the most common causes of GI bleeding, key patient history and risk factors, the optimal CT imaging technique, and guidelines for case interpretation and illustrates many common causes of GI bleeding. A CT reporting template is included to help generate radiology reports that can add value to patient care. An invited commentary by Al Hawary is available online. Online supplemental material is available for this article. ^©RSNA, 2021.

Large Hiatal Hernia Associated with Cameron Ulcers and Consecutive Sideropenic Anemia: Case Presentation

BACKGROUND: Cameron lesions are seen in 5.2% of patients with hiatal hernia who undergo esophagogastroduodenoscopic examinations. The prevalence of Cameron lesions seems to be dependent on the size of the hernial sac, with an increased prevalence in the larger-sized sac. In about two-thirds of the cases, multiple Cameron lesions are noted rather than a solitary erosion or ulcer. AIM: The aim of this case report is to present the patient with Cameron ulcers associated with hiatal hernia. CASE PRESENTATION: Our patient presented with postprandial retrosternal pain, especially immediately after eating, vomiting, dyspnea, weight loss, fatigue, signs, and symptoms of severe hypochromic microcytic anemia without signs of acute gastrointestinal bleeding. No history of gastroesophageal disease. Colonoscopy was done and eliminate colic cause of anemia. The endoscopy showed a large hiatal hernia and linear erosions and ulcerations at the level of gastrodiaphragmatic contact (Cameron ulcers) and one non-sanguinant subcardial elipsoid ulceration. After conservative and operative treatment, there was significant clinically and laboratory improvement definitively, after 6 months. Cameron lesion is a rare cause of refractory sideropenic anemia. Diagnosis is very difficult in developing countries, where iron deficiency anemia is more common. A history of disease, clinical course, and laboratory findings are the important facts for diagnosis. CONCLUSION: Endoscopy is the gold standard for diagnosis, although it is not uncommon to overlook these lesions due to their unique location. There are two modalities for the treatment of Cameron lesions: Medical or surgical, which should be individualized for each patient. By severe refractory anemia and large hiatal hernia, associated with clinical signs, surgical approach is very important.

Hiatal hernia and Cameron ulcer: an overlooked association in pediatric patients

A ten-year-old boy presented with a two-year history of iron deficiency anemia (IDA) and occasional vomiting. His medical history included cerebral palsy and chronic pulmonary disease under mechanical cough assistance and nocturnal non-invasive ventilation.

A 61-Year-Old Woman with Chronic Iron-Deficiency Anemia Due to a Cameron Lesion and a Response to Oral Application of Combined Poloxamer 407 with Hyaluronic Acid and Chondroitin Sulfate Following Single Treatment with Pantoprazole: A Case Report

BACKGROUND Cameron lesions are linear erosions and ulcers on the crests of gastric mucosal folds in the neck of a hiatal hernia and can be difficult to diagnose and treat. This report is of a case of chronic iron deficiency in a 61-year-old woman with a late diagnosis of a Cameron lesion, who did not respond to a single treatment with the proton pump inhibitor (PPI) pantoprazole, but was then treated with oral poloxamer 407 with hyaluronic acid and chondroitin sulfate in addition to PPI. CASE REPORT We report the case of a 61-year-old women with recurrent iron-deficiency anemia, first diagnosed 40 years prior to her presentation at our Endoscopy Unit, and an ongoing melena. We discovered an intrahiatal gastric mucosal defect, which we at first treated with proton pump inhibitors and sucralfate. After a follow-up gastroscopy revealed the persistence of the lesion, we decided to incorporate into the treatment a gel-like substance containing, among others, hyaluronic acid and chondroitin sulfate, and observed that the lesion resolved completely. CONCLUSIONS This report highlights that Cameron lesions should be considered in patients with hiatal hernia who have iron-deficiency anemia and can be diagnosed on upper endoscopy. Further clinical studies are required to determine the role of combined poloxamer 407 with hyaluronic acid and chondroitin sulfate in the management of Cameron lesions.

Surgical management of hiatal hernia vs medical therapy to treat bleeding Cameron lesions: a systematic review and meta-analysis

INTRODUCTION

Cameron lesions (CL) are an under-recognized cause of gastrointestinal bleeding. Diagnosis is often impaired by technical difficulty, and once diagnosed, management remains unclear. Typically, patients are medically managed with proton pump inhibitors (PPI). Small studies have demonstrated improved therapeutic success with surgical management, hypothesizing that reversing mechanical gastric trauma and ischemia allows CL healing. This systematic review and meta-analysis aim to compare therapeutic success of surgical versus medical management of Cameron lesions (CL).

METHODS AND PROCEDURES

A comprehensive search and systematic review selected manuscripts using the following inclusion criteria: (1) Endoscopically diagnosed CL (2) Treated surgically (3) Follow-up for resolution of anemia or CL (4) n ≥ 5 (5) Excluding non-English, animal, and studies with patients < 18 years old Meta-analysis was performed to compare resolution of CLs with medical and surgical therapy.

RESULTS

Systematic search retrieved 1664 studies, of these, 14 were included (randomized controlled trial = 1; prospective = 2; retrospective = 11). Patients had a mean age of 61.2 years (range 24-91) and were more often female (59.3%). Follow-up was between 3 and 120 months, and 82.9% of patients had hernias > 5 cm. Surgical management was associated with therapeutic success (OR 5.20, 1.83-14.77, I² = 42%, p < 0.001) with 92% having resolution, compared to 67.2% for those treated with PPI. Surgical complications occurred in 42/109 (38.5%) of patients (48.1% for Open Hill Repair, 15.4% for laparoscopic fundoplication). 40.0% of patients underwent a laparoscopic Nissen or Collis fundoplication, 21.7% underwent open modified Hill repair, and 38.3% had unspecified operations. Hemoglobin improved from 8.85 g/dL pre-operatively to 13.60 g/dL post-operatively. In six studies, surgical patients previously failed medical management.

CONCLUSIONS

This is the first systematic review comparing surgical and medical treatment of CL. Surgical management significantly improved therapeutic success. Our study supports therapeutic benefit of surgery in these patients.

Cameron Ulcers: Rare Case of Overt Upper Gastrointestinal Bleed in a Patient with Alcohol Use Disorder

Cameron lesion is an uncommon cause of overt upper gastrointestinal bleed (GI bleed). Though hiatal hernia is a well-known entity, Cameron lesions that may occur in them are usually missed during upper endoscopy. Patient with Cameron lesions usually presents as chronic iron deficiency anemia, rarely as acute GI bleed. Multiple other risk factors such as non-steroidal anti-inflammatory drug use, alcohol consumption, gastro-esophageal reflux disease (GERD) may be present concomitantly which makes initial differential diagnosis of Cameron lesions more difficult as seen in our case.

Large Cameron Ulcer Bleed

Cameron ulcers usually present with chronic obscure gastrointestinal bleeding. Few cases of life-threatening bleeding have been reported. We hereby present an elderly man who presented with upper gastrointestinal bleeding associated with hemodynamic instability because of a large cratered Cameron ulcer. This ulcer contained a large pseudoaneurysm, and endoscopic therapy was deemed unsafe. The patient had a recurrence of his bleeding, necessitating intervention by our interventional radiology colleagues and then surgical intervention for definitive therapy. This case is important because it familiarizes gastroenterologists with the endoscopic appearance of huge Cameron ulcers and therapeutic options to control hemostasis. It also stresses the importance of a multidisciplinary team approach to ensure the best outcomes for patients.

Cameron lesions: A still overlooked diagnosis. Case report and systematic review of literature

Cameron lesions are erosive-ulcerative alterations of gastric mucosa occurring in patients with large hiatal hernia, potentially causing gastrointestinal bleeding and iron deficiency anaemia. Diagnosis may be challenging, and not infrequently erosions are overlooked at endoscopy, so that repeated and unnecessary diagnostic procedures are performed, particularly in those patients with chronic anaemia. We described two peculiar cases of patients with iron deficiency anaemia in whom Cameron lesions were either overlooked or misinterpreted. By reviewing data of 22publications reporting endoscopic and clinical data of 140patients, we noted a large prevalence of females (75%). The most frequent presenting symptoms were anaemia (62%) and overt gastrointestinal bleeding (36%). Noteworthy, as many as 69% of patients underwent one or more previous upper endoscopy before diagnosis of Cameron lesion was achieved. Patients were mainly treated with proton pump inhibitor (PPI) therapy and iron supplementation. Moreover, endoscopic haemostasis was performed in 10% of case, blood transfusion was required in one third of cases, and a similar quote of patients underwent a surgical approach for hiatal hernia repair. The observation that as many as 60% patients were already receiving standard PPI therapy when diagnosis was performed would suggest that either long-term treatment with adequate dose PPI or surgical approach for hiatal hernia repair is required. In conclusion, Cameron lesion is still an overlooked diagnosis in patients with iron deficiency anaemia in whom a 5-9.2% prevalence has been reported.

Single-Incision Laparoscopic Transgastric Underrunning and Closure of Cameron Ulcers in Acute Gastrointestinal Bleeding

INTRODUCTION

Endoscopic therapy remains the cornerstone of hemostasis for gastrointestinal bleeding. In situations where hemostasis cannot be achieved via endoscopic or radiological methods, surgery is necessary. Traditional open surgery for bleeding gastric ulcers can be very morbid and unsuitable especially in hemodynamically unstable patients in extremis. We describe a minimally invasive, transgastric approach for underrunning and closure of Cameron ulcers.

METHODS

Our patient is a 75-year-old Chinese lady, who presented to the emergency department with fresh melena. She was hemodynamically unstable with severe metabolic acidosis. CT angiography revealed blood clots within the stomach, with no active blush. On urgent gastroscopy, large blood clots obscured the site of hemorrhage. A Mallory-Weiss tear was noted. Our patient subsequently underwent a successful single-incision laparoscopic transgastric (SLT) underrunning and closure of two Cameron ulcers.

RESULTS

Our patient had an uneventful recovery and subsequently underwent a successful laparoscopic para-esophageal hernia repair on postoperative day 9.

CONCLUSION

A SLT approach is a suitable minimally invasive option for the surgical management of hemostasis and closure of bleeding gastric ulcers not amenable to endoscopic or radiological interventions.

Unusual Causes of Upper Gastrointestinal Bleeding

Upper gastrointestinal (GI) bleeding is an important clinical condition managed routinely by endoscopists. Diagnostic and therapeutic options vary immensely based on the source of bleeding and it is important for the gastroenterologist to be cognizant of both common and uncommon etiologies. The focus of this article is to highlight and discuss unusual sources of upper GI bleeding, with a particular emphasis on both the clinical and endoscopic features to help diagnose and treat these atypical causes of bleeding.