Anaemia and hiatus hernia: experience in 450 patients

Updated Markov Model to Determine Optimal Management Strategy for Patients with Paraesophageal Hernia and Symptoms, Cameron Ulcer, or Comorbid Conditions

BACKGROUND

The current paradigm of watchful waiting (WW) in people 65 years or older with an asymptomatic paraesophageal hernia (PEH) is based on a now 20-year-old Markov analysis. Recently, we have shown that elective laparoscopic hernia repair (ELHR) provides an increase in life-years (L-Ys) compared with WW in most healthy patients aged 40 to 90 years. However, elderly patients often have comorbid conditions and may have complications from their PEH such as Cameron lesions. The aim of this study was to determine the optimal strategy, ELHR or WW, in these patients.

STUDY DESIGN

A Markov model with updated variables was used to compare L-Ys gained with ELHR vs WW in hypothetical people with any type of PEH and symptoms, Cameron lesions, and/or comorbid conditions.

RESULTS

In men and women aged 40 to 90 years with PEH-related symptoms and/or Cameron lesions, ELHR led to an increase in L-Ys over WW. The presence of comorbid conditions impacted life expectancy overall, but ELHR remained the preferred approach in all but 90-year-old patients with symptoms but no Cameron lesions.

CONCLUSIONS

Using a Markov model with updated values for key variables associated with management options for patients with a PEH, we showed that life expectancy was improved with ELHR in most men and women aged 40 to 90 years, particularly in the presence of symptoms and/or Cameron lesions. Comorbid conditions increase the risk for surgery, but ELHR remained the preferred strategy in the majority of symptomatic patients. This model can be used to provide individualized management guidance for patients with a PEH.

Laparoscopic hiatal hernia repair for treating patients with massive hiatal hernia and iron-deficiency anaemia

BACKGROUND

Massive hiatal hernias may result in extraoesophageal symptoms, including iron-deficiency anaemia. However, the role played by hiatal hernias in iron-deficiency anaemia is not clearly understood. We examined the prevalence of anaemia in patients with massive hiatal hernias and the frequency of anaemia resolution after laparoscopic hiatal hernia repair at long term follow-up.

METHODS

Patients who underwent laparoscopic hiatal hernia repair from June 2008 to June 2019 were enrolled in this study. We collected the patients' demographic and clinical data from their medical records, and compared the pre-surgical and post-surgical findings (at 1 week and 3 months post-surgery). All patients with adequate documentation underwent post-surgical follow-up to evaluate improvements in clinical symptoms and signs.

RESULTS

A total of 126 patients with massive hiatal hernias underwent laparoscopic hiatal hernia repair. Of these, 35 (27.8%) had iron-deficiency anaemia. Anaemia was resolution in all the patients and they had significantly reduced GERD-Q scores at 3 months postoperatively (P<0.01) .The mean follow-up period was 60 months. Iron-deficiency anaemia resolution after hiatal hernia repair was achieved in 93.9% of the patients.

CONCLUSION

Anaemia is common in patients with massive hiatal hernias, and most of our patients were symptomatic because of their anaemia. Moreover, in patients with massive hiatal hernias, iron-deficiency anaemia resolution is likely after laparoscopic hiatal hernia repair.

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.

Paraesophageal hernia and iron deficiency anemia: Mechanisms, diagnostics and therapy

There is ample clinical evidence suggesting that the presence of large axial or paraesophageal hernias may lead to iron deficiency anemia. So-called Cameron lesions, as well as other small mucosa erosions, in the sliding area of these diaphragmatic hernias lead to invisible chronic blood loss and consequently to iron depletion. While the spectrum of symptoms in these patients is large, anemia is often not the only indication and typically not the primary indication for surgical correction of diaphragmatic hernias. Drug treatment with proton pump inhibitors and iron substitution can alleviate anemia, but this is not always successful. To exclude other possible bleeding sources in the gastrointestinal tract, a comprehensive diagnostic program is necessary and reviewed in this manuscript. Additionally, we discuss controversies in the surgical management of paraesophageal hernias.

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.

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.

Resolution of anemia and improved quality of life following laparoscopic hiatal hernia repair

BACKGROUND

Cameron lesions (CL) are common complications of large hiatal hernia (HH) disease and are known to result in chronic blood loss with resultant microcytic anemia. There is support in the literature that repair of HH may lead to resolution of CL and restore normal hemoglobin levels. This study aimed to determine the impact of elective HH repair on resolution of anemia and the quality of life (QOL) in patients with CL.

METHOD

A single-institution, retrospective review analyzed all patients with history of CL or anemia (hemoglobin < 12.0 gm/dl in women, < 13.5 gm/dl in men) who underwent HH repair from January 2012 to May 2019. Four validated surveys were used to assess QOL: Reflux Symptom Index (RSI), gastroesophageal reflux disease health-related QOL (GERD-HRQL), laryngopharyngeal reflux health-related QOL (LPR-HRQL), and QOL and swallowing disorders (SWAL) survey. History of iron supplements and perioperative hemoglobin were also noted.

RESULT

Ninety-six patients were included in this study. The mean age was 67.4 ± 10.8 years and 79% of patients were female. CL were endoscopically identified in 61.5% of patients preoperatively, and the rest of the patients experienced anemia of undiagnosed origin but had a high suspicion for CL. Mean follow-up after HH repair was 17.3 months (range, 1 month-5 years). Mean preoperative hemoglobin was 11.01 ± 2.9 gm/dl and 13.23 ± 1.6 gm/dl postoperatively (p < 0.01). Forty-two (73.7%) patients had resolution of anemia during follow-up and 94.5% stopped supplemental oral iron. Finally, QOL scores significantly improved after surgical intervention: RSI (63%), GERD-HRQL (77%), LPR-HRQOL (72%), and SWAL (13%).

CONCLUSION

Elective HH repair in patients with chronic anemia secondary to CL may potentially resolve CL and anemia and contribute to significant QOL improvements. Future studies will prospectively assess the resolution of CL with biochemical and endoscopic follow-up to confirm the preliminary findings of our analysis.

Paraesophageal hernia repair: a curative consideration for chronic anemia?

INTRODUCTION

Chronic anemia is a common, coinciding or presenting diagnosis in patients with paraesophageal hernia (PEH). Presence of endoscopically identified ulcerations frequently prompts surgical consultation in the otherwise asymptomatic patient with anemia. Rates of anemia resolution following paraesophageal hernia repair (PEHR) often exceed the prevalence of such lesions in the study population. A defined algorithm remains elusive. This study aims to characterize resolution of anemia after PEHR with respect to endoscopic diagnosis.

MATERIALS AND METHODS

Retrospective review of a prospectively maintained database of patients with PEH and anemia undergoing PEHR from 2007 to 2018 was performed. Anemia was determined by preoperative labs: Hgb < 12 mg/dl in females, Hgb < 13 mg/dl in males, or patients with ongoing iron supplementation. Improvement of post-operative anemia was assessed by post-operative hemoglobin values and continued necessity of iron supplementation.

RESULTS

Among 56 identified patients, 45 were female (80.4%). Forty patients (71.4%) were anemic by hemoglobin value, 16 patients (28.6%) required iron supplementation. Mean age was 65.1 years, with mean BMI of 27.7 kg/m². One case was a Type IV PEH and the rest Type III. 32 (64.0%) had potential source of anemia: 16 (32.0%) Cameron lesions, 6 (12.0%) gastric ulcers, 12 (24.0%) gastritis. 10 (20.0%) had esophagitis and 4 (8%) Barrett's esophagus. 18 (36%) PEH patients had normal preoperative EGD. Median follow-up was 160 days. Anemia resolution occurred in 46.4% of patients. Of the 16 patients with pre-procedure Cameron lesions, 10 (63%) had resolution of anemia. Patients with esophagitis did not achieve resolution. 72.2% (13/18) of patients with no lesions on EGD had anemia resolution (p = 0.03).

CONCLUSION

Patients with PEH and identifiable ulcerations showed 50% resolution of anemia after hernia repair. Patients without identifiable lesions on endoscopy demonstrated statistically significant resolution of anemia in 72.2% of cases. Anemia associated with PEH adds an indication for surgical repair with curative intent.

Preoperative anemia: a common finding that predicts worse outcomes in patients undergoing primary hiatal hernia repair

BACKGROUND

The increased incidence of anemia in patients with hiatal hernias (HH) and resolution of anemia after HH repair (HHR) have been clearly demonstrated. However, the implications of preoperative anemia on postoperative outcomes have not been well described. In this study, we aimed to identify the incidence of preoperative anemia in patients undergoing primary HHR at our institution and sought to determine whether preoperative anemia had an impact on postoperative outcomes.

METHODS

Using our IRB-approved institutional HH database, we retrospectively identified patients undergoing primary HHR between January 2011 and April 2017 at our institution. We identified patients with anemia, defined as serum hemoglobin levels less than 13 mg/dL in men and 12 mg/dL in women, measured within two weeks prior to surgery, and compared this group to a cohort of patients with normal preoperative hemoglobin. Perioperative outcomes analyzed included estimated blood loss (EBL), operative time, perioperative blood transfusions, failed postoperative extubation, intensive care unit (ICU) admission, postoperative complications, length of stay (LOS), and 30-day readmission. Outcomes were compared by univariable and multivariable analyses, with significance set at p < 0.05.

RESULTS

We identified 263 patients undergoing HHR. The median age was 66 years and most patients were female (78%, n = 206). Seventy patients (27%) were anemic. In unadjusted analyses, anemia was significantly associated with failed postoperative extubation (7 vs. 2%, p = 0.03), ICU admission (13 vs. 5%, p = 0.03), postoperative blood transfusions (9 vs. 0%, p < 0.01), and postoperative complications (41 vs. 18%, p < 0.01). On adjusted multivariable analysis, anemia was associated with 2.6-fold greater odds of postoperative complications (OR 2.57; 95% CI 1.36-4.86; p < 0.01).

CONCLUSIONS

In this study, anemia had a prevalence of 27% in patients undergoing primary HHR. Anemic patients had 2.6-fold greater odds of developing postoperative complications. Anemia is common in patients undergoing primary HHR and warrants consideration for treatment prior to elective repair.

Acute abdomen in a patient with paraesophageal hernia, resulting in acute compromised respiratory function: A case report

INTRODUCTION

We present a case of acute abdomen, causing increased intra-abdominal pressure, leading to further herniation of an existing paraesophageal hernia, and consequently acute compromised respiratory function. This acute respiratory complication to a paraesophageal hernia has not previously been reported.

PRESENTATION OF CASE

We present a case of a 75-year-old female who was acutely admitted with stridor. The patient was known to have a paraesophageal hernia monitored using watchful waiting, and dyspnoea. The patient's condition deteriorated, leading to intubation. Diagnostic imaging revealed a paraesophageal hernia pressing onto the trachea as well as appendicitis and ileus. Surgery confirmed perforated appendicitis, peritonitis, and ileus causing high intra-abdominal pressure, resulting in further herniation of the paraesophageal hernia as a cause for acute compromised respiratory function. Appendectomy and gastropexy were performed. The patient was later discharged to rehabilitation.

DISCUSSION

Patients with pulmonary symptoms caused by a paraesophageal hernia, especially patients with sizeable hernias, could potentially be in greater risk of severe airway affection if complicated by acute abdomen. These patients could benefit from elective hernia repair, rather than watchful waiting, as it would eliminate pulmonary symptoms and prevent similar cases. Patients monitored using watchful waiting should be informed that acute abdomen could cause acute compromised respiratory function.

CONCLUSION

Any case of acute abdomen causing high intra-abdominal pressure could potentially cause further herniation of an existing paraesophageal hernia, resulting in acute compromised respiratory function. In patients known to have a paraesophageal hernia, similar cases should be suspected if the patient presents with acute breathing difficulties.

A Large Intra-Abdominal Hiatal Hernia as a Rare Cause of Dyspnea

Giant hiatal hernias, generally seen at advanced ages, can rarely cause cardiac symptoms such as dyspnea and chest pain. Here, we aimed to present a case with a large hiatal hernia that largely protruded to intrathoracic cavity and caused dyspnea, particularly at postprandial period, by compressing the left atrium and right pulmonary vein. We considered presenting this case as large hiatal hernia is a rare, intra-abdominal cause of dyspnea.

Cameron lesions in patients with hiatal hernias: prevalence, presentation, and treatment outcome

Cameron lesions, as defined by erosions and ulcerations at the diaphragmatic hiatus, are found in the setting of gastrointestinal (GI) bleeding in patients with a hiatus hernia (HH). The study aim was to determine the epidemiology and clinical manifestations of Cameron lesions. We performed a retrospective cohort study evaluating consecutive patients undergoing upper endoscopy over a 2-year period. Endoscopy reports were systematically reviewed to determine the presence or absence of Cameron lesions and HH. Inpatient and outpatient records were reviewed to determine prevalence, risk factors, and outcome of medical treatment of Cameron lesions. Of 8260 upper endoscopic examinations, 1306 (20.2%) reported an HH. When categorized by size, 65.6% of HH were small (<3 cm), 23.0% moderate (3-4.9 cm), and 11.4% were large (≥5 cm). Of these, 43 patients (mean age 65.2 years, 49% female) had Cameron lesions, with a prevalence of 3.3% in the presence of HH. Prevalence was highest with large HH (12.8%). On univariate analysis, large HH, frequent non-steroidal anti-inflammatory drug (NSAID) use, GI bleeding (both occult and overt), and nadir hemoglobin level were significantly greater with Cameron lesions compared with HH without Cameron lesions (P ≤ 0.03). Large HH size and NSAID use were identified as independent risk factors for Cameron lesions on multivariate logistic regression analysis. Cameron lesions are more prevalent in the setting of large HH and NSAID use, can be associated with GI bleeding, and can respond to medical management.

Treatment and controversies in paraesophageal hernia repair

Background

Historically all paraesophageal hernias were repaired surgically, today intervention is reserved for symptomatic paraesophageal hernias. In this review, we describe the indications for repair and explore the controversies in paraesophageal hernia repair, which include a comparison of open to laparoscopic paraesophageal hernia repair, the necessity of complete sac excision, the routine performance of fundoplication, and the use of mesh for hernia repair.

Methods

We searched Pubmed for papers published between 1980 and 2015 using the following keywords: hiatal hernias, paraesophageal hernias, regurgitation, dysphagia, gastroesophageal reflux disease, aspiration, GERD, endoscopy, manometry, pH monitoring, proton pump inhibitors, anemia, iron-deficiency anemia, Nissen fundoplication, sac excision, mesh, and mesh repair.

Results

Indications for paraesophageal hernia repair have changed, and currently symptomatic paraesophageal hernias are recommended for repair. In addition, it is important not to overlook iron-deficiency anemia and pulmonary complaints, which tend to improve with repair. Current practice favors a laparoscopic approach, complete sac excision, primary crural repair with or without use of mesh, and a routine fundoplication.

Iron-deficiency anemia is a common presenting issue with giant paraesophageal hernia and resolves following repair

BACKGROUND

A significant percentage of patients with paraesophageal hernia (PEH) will have a co-existing diagnosis of iron-deficiency anemia which will resolve following surgical repair.

METHODS

Between 2000 and 2010, 270 patients underwent operative repair of PEH. Of this group, 123 patients (45.6 %) reported a preexisting diagnosis of iron-deficiency anemia. The study group consisted of 77 patients with a documented preoperative hemoglobin level (Hb) consistent with iron-deficiency anemia and a follow-up level at least 3 months following surgery.

RESULTS

Of the 77 patients included, 72 underwent elective repair, median age was 75 (39-91) years, and 65 % were female. Cameron erosions were identified preoperatively in 32 %. Mean preoperative hemoglobin was 9.6 (4.4-13.6) g/dl and postoperative hemoglobin was 13.2 (10.7-17) g/dl at 3-12 months and 13.6 (9.7-17.2) g/dl at more than 1 year. Ninety percent of patients had a rise in postoperative hemoglobin level by at least 1 g/dL. Anemia resolved in 55 (71 %) patients, more often in women and younger patients (<70 years). Twenty-nine of 40 (73 %) patients on iron therapy discontinued this postoperatively.

CONCLUSION

A significant number of patients who present with giant PEH will present with iron-deficiency anemia. Elective repair will result in resolution of the anemia in more than 70 % of patients. PEH is underappreciated as a source of iron-deficiency anemia, and appropriate patients should be considered for elective repair.

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

We report a case series of all consecutive patients hospitalized in our two tertiary referral medical centers over the past 17 years for Cameron ulcers causing severe upper gastrointestinal hemorrhage (GIH) or severe obscure GIH. Cameron ulcers were diagnosed in 25 of the 3960 screened patients with severe upper GIH or severe obscure GIH (0.6 %). Of these, 21 patients had a prospective follow-up (median time 20.4 months [interquartile range: 8.5 - 31.8]). Patients were more often elderly women with chronic anemia, always had large hiatal hernias, and were usually referred for obscure GIH. Twelve of the 21 patients (57 %) were referred for surgery while being treated with high-dose proton pump inhibitors (PPIs). The other 9 patients (43 %) continued PPIs without any rebleeding during the follow-up. Cameron ulcers in large hiatal hernias are an uncommon cause of severe upper GIH. The choice of medical vs. surgical therapy should be individualized.

Prevalence and resolution of anemia with paraesophageal hernia repair

BACKGROUND

Paraesophageal hernias may produce a variety of clinical sequelae including anemia and esophagogastric ulcerations or erosions. We examined the prevalence of anemia in patients with paraesophageal hernias and frequency of anemia resolution with hernia repair.

METHODS

Patients undergoing paraesophageal hernia repairs from July 1996 to September 2010 were included. Data gathered included age, gender, type of hernia, presence of symptomatic anemia, presence of esophagogastric ulcer/erosion, type of repair, and anemia resolution.

RESULTS

One hundred eighty-three patients underwent paraesophageal hernia repair; of these, 68 (37%) were anemic. Of these anemic patients, 39 (57%) were symptomatic from their anemia or specifically referred for anemia, and 20 (29%) had esophagogastric ulceration/erosion. Fifty-eight had documented follow-up. Overall, of these, 35 (60%) had resolution of their anemia. Seventy percent of symptomatic patients had resolution of their anemia, compared to 48% of asymptomatic patients (p = 0.1). Of patients with esophagogastric ulceration/erosion, 85% were symptomatic and 88% had resolution of anemia, compared to 50% of patients without ulceration/erosion (p = 0.015).

CONCLUSIONS

Anemia was a common finding in patients with paraesophageal hernia and most patients were symptomatic because of their anemia. Those patients with esophageal or gastric ulceration/erosion were very likely to have symptomatic anemia, and, interestingly, these patients were more likely to have their anemia resolve with paraesophageal hernia repair.

Clinical ramifications of giant paraesophageal hernias are underappreciated: making the case for routine surgical repair

BACKGROUND

We propose that the symptoms associated with paraesophageal hernia (PEH) are more diverse than previously suggested, and symptoms and clinical manifestations correlate to the anatomy of the hernia.

METHODS

Patients undergoing surgery for PEH were reviewed from a prospective, institutional review board-approved, single-center database. Presenting symptoms, anatomy of the PEH, demographics, and outcomes were analyzed from 2000 to 2010. Presenting symptoms were assessed for incidence and improvement after surgery. Size and configuration of the PEH were assessed with respect to presenting symptoms.

RESULTS

The study included 270 consecutive patients, 63% were female, and the median age was 70 years (range, 39 to 94 years). The most common presenting symptoms were heartburn in 175 patients (65%), early satiety in 136 patients (50%), chest pain in 130 patients (48%), dyspnea in 130 patients (48%), dysphagia in 129 patients (48%), regurgitation in 128 patients (47%), and anemia in 112 patients (41%). Two hundred sixty-nine patients (99.6%) had at least one symptom; the median number of symptoms was 4 (range, 0 to 10). The type of PEH was II (n=10), III (n=206), and IV (n=54), and the percent intrathoracic stomach was less than 50% (n=33), 50% to 74% (n=86), 75% to 99% (n=55), and 100% (n=96). Paraesophageal hernia type was significantly associated with heartburn (type II/III; p=0.005) and dyspnea (type IV; p=0.007). Significant associations included lower percent intrathoracic stomach with regurgitation (p=0.04); higher percent intrathoracic stomach with early satiety (p=0.02), decreased meal size (p=0.007), and dyspnea (p<0.001); and 50% to 74% intrathoracic stomach with anemia (p=0.001). With a median postoperative follow-up of 103 days, symptoms were subjectively better in patients with dyspnea (67%), early satiety (79%), regurgitation (92%), dysphagia (81%), chest pain (76%), and heartburn (93%).

CONCLUSIONS

Paraesophageal hernia is associated with a greater diversity of symptomatic presentation than previously thought. Asymptomatic patients are rare, and size and configuration of the hernia are associated with specific symptoms. Patients with large PEHs should be assessed by an experienced surgeon for elective repair.

Cameron lesions: an often overlooked cause of iron deficiency anaemia in patients with large hiatal hernias

Cameron lesions are linear gastric ulcers or erosions on the mucosal folds at the diaphragmatic impression in patients with a large hiatal hernia. The lesions are associated with occult bleeding and development of chronic iron deficiency anaemia, but are often overlooked during routine endoscopy. We present two patients with known hiatal hernias in who repeated endoscopic examinations had not been able to identify a source of bleeding. In both cases, typical Cameron lesions were found either by repeat gastroscopy or by capsule endoscopy. Treatment with high-dose proton pump inhibitor and iron supplement was initiated.

Effect on iron deficiency anemia of laparoscopic repair of large paraesophageal hernias

Patients with iron deficiency anemia sometimes have a large paraesophageal hernia and no other explanation for their chronic blood loss. The management of these patients can be a dilemma, especially when the hernia is otherwise asymptomatic. We aimed to determine whether a laparoscopic repair of the hernia could cure the anemia. We reviewed a consecutive series of 11 cases of iron deficiency anemia associated with a large paraesophageal hernia, many without associated linear gastric erosions, managed by laparoscopic repair and fundoplication. There was one conversion in a patient with dense adhesions from previous upper abdominal surgery. Another patient required a laparoscopic reoperation for an early recurrence. Major morbidity occurred in three patients and there was no mortality. There was no recurrence of anemia after a median follow-up of more than 2 years. Iron deficiency anemia in association with a large paraesophageal hernia can be treated by laparoscopic repair with acceptable morbidity and minimal mortality. The complications of a large paraesophageal hernia are also prevented.

Large hiatal hernia and iron deficiency anaemia: clinico-endoscopical findings

BACKGROUND

Iron deficiency anaemia (IDA) in men and postmenopausal women is mostly due to chronic gastrointestinal blood loss. One of the most common missed lesions while performing upper endoscopy in the work-up of IDA, are Cameron lesions, located at the neck of a large hiatal hernia.

AIMS

Description of the bio-clinical and endoscopic findings of a large hiatal hernia, diagnosed in patients presenting with iron deficiency anaemia. Furthermore, a review of the literature concerning the diagnostic and therapeutic management of these patients will be outlined.

STUDY

We retrospectively evaluated 36 patients, presenting with IDA (hemoglobin < 10 g/dl) associated with a large hiatal hernia.

RESULTS

Cardiopulmonary complications of anaemia were the presenting symptoms, rather than gastrointestinal related complaints or bleeding. Cameron lesions were visualized only in 18 (50%) of our patients at their first presentation. There was no obvious correlation between the presence of Cameron lesions and visible gastrointestinal blood loss. Initially, almost all of our patients were treated medically. Seven underwent surgical repair of the hiatal hernia and all remained asymptomatic afterwards.

CONCLUSION

We conclude that a hiatal hernia, with or without visible Cameron lesions, is a real and maybe underestimated cause of IDA. Finding a large hiatal hernia on upper endoscopy, together with a negative colonoscopy, completes the diagnostic work-up of IDA in most of these elderly patients. Currently, no guidelines concerning the optimal therapeutic management of this problem are available. Therapy may depend upon the need of transfusion, the efficiency of medical treatment, the risks of surgery and the preference and general condition of the patient.

Large hiatal hernia in patients with iron deficiency anaemia: a prospective study on prevalence and treatment

BACKGROUND

Although large hiatal hernia may cause bleeding from Cameron erosions, its role in iron deficiency anaemia has been debated, and no data are available on the treatment of these patients with proton pump inhibitors. Aims : To determine the prevalence of large hiatal hernia in out-patients with iron deficiency anaemia and the role of proton pump inhibitors in the prevention of recurrence of anaemia.

METHODS

Two hundred and twenty-eight out-patients underwent upper/lower endoscopy. Those with large hiatal hernia were given an oesophagogram, discontinued iron supplementation and received proton pump inhibitor treatment with (group 1) or without (group 2) surgery. Anaemia was re-assessed during 1 year of follow-up.

RESULTS

Large hiatal hernia was the likely cause of anaemia in 21 patients (9.2%). The median haemoglobin and ferritin values at the diagnosis of anaemia were 7.9 g/dL and 6 micro g/L, respectively. Cameron erosions were found in 33% of patients. Ten and eleven patients were included in groups 1 and 2, respectively. Haemoglobin values were 13.8 g/dL and 13.4 g/dL at 3 months of follow-up, and 13.4 g/dL and 13.8 g/dL at 1 year of follow-up, in groups 1 and 2, respectively.

CONCLUSIONS

Large hiatal hernia may cause iron deficiency anaemia, even without Cameron erosions. Surgery in combination with proton pump inhibitor therapy is no better than proton pump inhibitor therapy alone in preventing the recurrence of anaemia.

Plummer-Vinson syndrome associated with chronic blood loss anemia and large diaphragmatic hernia

The coexistence of large diaphragmatic hernia and Plummer-Vinson syndrome in two patients is described. It is proposed that the hernias caused chronic blood loss anemia, and that iron deficiency then resulted in postcricoid web formation.

Diagnostic and therapeutic impact of push enteroscopy: analysis of factors associated with positive findings

BACKGROUND

Push enteroscopy is indicated in patients with suspected small bowel gastrointestinal bleeding or small bowel mucosal disease. Our aim was to determine the diagnostic yield of enteroscopy, identify clinical predictors associated with findings, and measure frequency of management changes made on the basis of results.

METHODS

Endoscopy reports, office charts, and hospital charts were reviewed for 164 patients who had enteroscopy performed, primarily with a video enteroscope, during a period of 2 years. Data extraction included details of comorbid illnesses, associated risk factors, and previous endoscopies.

RESULTS

Indications for enteroscopy were suspected occult bleeding in 65, overt bleeding in 64, diarrhea in 20, and suspected mucosal disease in 15 patients. Diagnostic lesions, identified in 92 patients (56%), included 57 jejunal lesions (35%). In patients with overt bleeding, upper tract lesions were present more commonly in patients receiving nonsteroidal medication (54% versus 27%, p < 0.05). Jejunal vascular ectasia occurred more frequently in patients with documented vascular ectasias elsewhere in the gastrointestinal tract (34% versus 15%, p < 0.01). Missed lesions on previous upper endoscopy included large hiatal hernias with erosions in 10, peptic ulcers in 10, and vascular ectasias in 9 patients. Therapeutic interventions, made in 67 of 92 patients (73%) with diagnostic lesions, included small bowel resection in 12 (8%), endoscopic therapy in 21 (14%), and changes in medical regimen in 34 patients (22%).

CONCLUSIONS

Push enteroscopy with video enteroscopes has a moderate diagnostic yield. Positive findings frequently lead to therapy changes. Large hiatal hernias remain an under-recognized etiology of anemia. Repeat upper endoscopy should be considered before enteroscopy in patients taking nonsteroidals who develop overt bleeding.

Hiatal hernia with cameron ulcers and erosions

Cameron lesions are seen in 5.2% of patients with hiatal hernias who undergo EGD examinations. The prevalence of Cameron lesions seems to be dependent on the size of the hernia sac, with an increased prevalence the larger the hernia sac. In about two thirds of the cases, multiple Cameron lesions are noted rather than a solitary erosion or ulcer. Historically, Cameron lesions present clinically with chronic GI bleeding and associated iron deficiency anemia. With increased awareness of the existence of this lesion, however, it is now more frequently seen as an incidental finding during EGD. Cameron lesions can also present as acute upper GI bleeding, occasionally life-threatening, in up to one third of cases. Therefore, Cameron lesions should be considered in any patient in whom a hiatal hernia is noted during endoscopic examination. Concomitant acid-peptic diseases are seen in a majority of individuals, especially reflux esophagitis and its complications. Mechanical trauma, ischemia, and acid mucosal injury may play a role in the pathogenesis of Cameron lesions. The choice of therapy of Cameron lesions, medical or surgical, should be individualized for each patient. Of those patients who were treated with a spectrum of medical therapy and who have had long-term follow-up, about one third have had a recurrence of the lesion and 17% (8/48) have developed complications, most commonly either acute upper GI bleeding (6.3%) or persistent and recurrent iron deficiency anemia (8.3%).

A prospective study of the gastroenterological causes of iron deficiency anaemia in a general hospital

BACKGROUND

Current practice is to investigate routinely both upper and lower gastrointestinal tracts in patients with unexplained iron deficiency anaemia.

AIMS

To determine the efficacy of this approach and whether the use of more stringent biochemical criteria for iron deficiency, symptoms, or a positive immunochemical faecal human haemoglobin (FHH) influenced the findings of the investigations and could help target investigations more efficiently.

METHODS

Eighty patients were studied prospectively, 51 who had "definite' iron deficiency anaemia (low ferritin and transferrin saturation) and 29 with "probable' iron deficiency anaemia (either low ferritin or transferrin saturation). Patients underwent a standardised symptom assessment and testing for FHH, upper endoscopy with small bowel biopsy and colonoscopy, and a small bowel series if upper endoscopy and colonoscopy were negative.

RESULTS

Lesions potentially causative for iron deficiency anemia were found in 54/80 (60%) of patients. Five patients (7%) had lesions in both upper and lower tracts. Small bowel biopsy was abnormal in one of 80 patients and small bowel series one of 25 patients. Significant lesions in either the upper or lower gastrointestinal tract were found in 14/20 patients with positive FHH and 25/47 with negative FHH. Symptoms, use of non-steroidal anti-inflammatory drugs and classification of patients into "definite' and "probable' iron deficiency did not influence yield of investigations or site of lesions found.

CONCLUSIONS

Gastrointestinal lesions are common in patients with unexplained iron deficiency anaemia. Neither symptoms nor presence of FHH predict the presence of site of detectable lesions and neither testing for FHH nor more stringent biochemical criteria for iron deficiency alters clinical decision making. The findings support the routine performance of both upper endoscopy and colonoscopy in the investigation of patients with unexplained iron deficiency anaemia, however routine investigation of the small bowel is of questionable value.

Diaphragmatic hernia and associated anemia: response to surgical treatment

From 1985 to 1993, 49 patients (35 women and 14 men) with diaphragmatic hernia and associated anemia underwent surgical repair. The median age was 64.5 years (range 24 to 84 years). Hematologic and gastroenterologic evaluations revealed no other potential cause of bleeding. Each patient had a diaphragmatic hernia. The median time between the diagnosis of anemia and surgical repair was 36 months (range 1 to 334 months). Forty-five patients (91.8%) had received replacement therapy, including iron for 43 and blood transfusions for 32 (median 6 units; range 2 to 70 units). Forty-six patients (93.9%) had symptoms: heartburn in 28, early satiety with bloating in 19, regurgitation in 11, dysphagia in 7, and aspiration in 4. Preoperative upper gastrointestinal endoscopic evaluation demonstrated gastric erosions at the level of the hiatus in 22 patients (44.9%), esophagitis in 7, stenosis in 1, and Barrett's disease in 1. An uncut Collis-Nissen fundoplication was performed in 44 patients, Belsey fundoplication in 2, a cut Collis-Nissen fundoplication, Nissen fundoplication, and Hill repair in 1 each. There was one operative death (2% mortality). Complications occurred in 18 patients (36.7%). Follow-up was complete and ranged from 4 to 103 months (median 63 months). Forty-five patients (91.8%) had resolution of their anemia. Functional results were excellent in 40 patients (81.6%), good in 2 (4.1%), fair in 4 (8.2%), and poor in 3 (6.1%). In most patients with diaphragmatic hernia and associated anemia refractory to medical treatment, surgical repair can result in successful resolution of the anemia.

Hiatal hernial ulcers: clinical features and follow-up

We describe the clinical features and therapeutic outcome in 49 patients in whom benign gastric ulceration of an hiatal hernia was demonstrated endoscopically. Hiatal hernia ulcers accounted for 10% of all benign gastric ulcers. The typical patient was an elderly female with a history of dyspepsia who was receiving non-steroidal anti-inflammatory drugs. Twenty-seven (55%) patients had evidence of haemorrhage (acute in 15; chronic in 12) from the hiatal hernial ulcer at presentation. In 16 (33%) patients, symptoms attributable to haemorrhage constituted the sole clinical evidence of the hiatal hernial ulcer. Acute haemorrhage from hiatal hernial ulcers was associated with non-steroidal anti-inflammatory drug (NSAID) treatment (P less than 0.05). Chronic blood loss from hiatal hernial ulcers was associated with female gender (P less than 0.005) but not with NSAID treatment. Hiatal hernial ulcers healed slowly in response to medical treatment with H2-receptor antagonists (median time to healing 12 weeks). Surgical treatment may be the therapy of choice for hiatal hernial ulcers because of the high complication rate, poor response to medical therapy, and the apparent predominance of mechanical aetiological factors.

Linear gastric erosion. A lesion associated with large diaphragmatic hernia and chronic blood loss anemia

A prospective study was undertaken to identify mucosal lesions that might cause chronic blood loss anemia in patients with large diaphragmatic hernia. Patients with one-third or more of the stomach above the diaphragm on barium x-ray were examined by a gastroscopist who was given no clinical information. A total of 109 patients were included: 55 with anemia and 54 with a large hernia but no anemia. The incidence of esophagitis and peptic ulcer did not differ significantly in the anemic and nonanemic groups. Linear gastric erosions were found on the crests of mucosal folds at or near the level of the diaphragm in 23 anemic patients and 13 without anemia (p less than 0.05). Blood on the surface of a linear erosion was found in 14 anemic patients and 4 without anemia (p less than 0.05). We suggest that these erosions are due to trauma and can cause chronic blood loss anemia in hernia patients.

Gastric ulceration after Nissen fundoplication

Thirteen patients developed gastric ulcers between 6 months and 8.5 years after Nissen fundoplication. Eight patients presented with epigastric pain alone, 3 with bleeding alone and 2 with both pain and bleeding. Nine ulcers (69 per cent) were high on the lesser curve, close to the fundoplication and 7 of these patients had recurrent hernias. Anatomical distortion produced by fundoplication is probably the most important aetiological factor, though gastric distention, bile reflux gastritis and ischaemia may be contributory.

Massive hiatal hernia with incarceration: a report of 53 cases

Between 1960 and 1980, 53 patients with massive incarcerated hiatal hernia were treated surgically. In 24 of the 53 patients, there was an associated organoaxial volvulus. The following symptoms and signs, which are almost peculiar to massive, incarcerated hernias, were observed: postprandial precordial distress in 43 patients, upper gastrointestinal bleeding (manifest or occult) in 24 patients, severe dyspnea in 13 patients, and complete obstruction associated with organoaxial volvulus in 4. In only 1 of the 53 patients was the hernia of the true paraesophageal type with the esophagogastric junction remaining in its normal, intraabdominal location. The remainder were all believed to be advanced stages of an ordinary sliding hiatal hernia. Operative treatment consisted of gastroplasty and partial fundoplication in 36 patients, standard Belsey repair in 14, and transabdominal Nissen repair in 3. Gastroplasty and partial fundoplication were used much more frequently during the 1970s, when it was realized that there is a significant incidence of chronic peptic esophagitis and shortening in these patients. Postoperative complications were few in spite of the advanced age of many of the patients. There was one operative death. Only 1 patient was lost to follow-up, and of the 51 patients remaining for analysis, follow-up has extended from 1 to 16 years, with a mean of 6.2 years. No patient has developed recurrent precordial pain, evidence of upper gastrointestinal bleeding, iron deficiency anemia, or severe dyspnea. Seven patients have residual dysphagia; this condition is minimal in 5, and is significant in 2 who require interval esophageal dilation. Nine patients have symptomatic reflux, which is minimal in 5 patients, moderate in 2 patients, and severe in 2 others who were subsequently reoperated on. Contrary to popular concept, our observations indicate that almost all of these patients represent advanced degrees of sliding hiatal hernia with intrathoracic displacement of the esophagogastric junction. This implies a need for an adequate antireflux reconstruction in all patients undergoing operation, as well as an awareness that unanticipated cicatricial changes may be present in the distal esophagus and may prejudice the success of some of the standard hiatal repairs.

Hiatal hernia complicated by gastric ulceration and perforation

The incidence of gastric ulcer in hiatal hernia is highest in para-esophageal hernia and in chronic incarcerated hernia in older patients. Two patients with chronic incarcerated sliding hernias complicated by unrecognized gastric ulceration and perforation are described. One patient developed a subhepatic and mediastinal abscess; the other developed a gastropleural fistula. The incidence, clinical and roentgen findings, complications, and treatment of gastric ulcers in hiatal hernia are discussed.

Iron deficiency anaemia--a prospective study

A prospective study was performed over 15 months to determine the cause of iron deficiency in adult males and postmenopausal females attending a general hospital. The laboratory computer identified all subjects with a haemoglobin less than 10.6 g/dl and a mean corpuscular volume less than 86 fl. Patients becoming anaemic after trauma or recent surgery were excluded. The iron status of each patient was assessed by serum iron studies, serum ferritin or sternal marrow aspiration. Reduced red cell indices and blood film morphology were not diagnostic of iron deficiency. Of 215 patients assessed, about half (103) were found to be iron replete. This group had a variety of disorders--malignancy, chronic inflammation, chronic renal and non-malignant haematological diseases. The other group of 104 patients satisfied criteria for iron deficiency, and 100 of these were investigated further. The cause of iron deficiency was found in all but three subjects. Inadequate dietary intake was a contributing factor in over half of the patients and 40 regularly took salicylates. Investigation defined a source of chronic gastrointestinal blood loss in most instances.

Gastric ulceration within hiatus hernia

A retrospective analysis has been made of 19 persons with gastric ulceration in hiatus hernias. Eleven patients presented with acute upper gastrointestinal haemorrhage and three with chronic anaemia. Seventeen had experienced previous abdominal discomfort or heartburn. Diagnosis of ulceration was achieved by endoscopy in 16 instances and by radiography in six instances. A chronic ulcer was found in 10 patients, a discrete acute ulcer in three and multiple erosions in six. Twelve of the hernias were sliding in type and irreducible, in contrast to previous reports that gastric ulceration is most frequent in paracoesophageal hernias. Conservative management resulted in complete healing of the ulcer in the majority of patients. Continued bleeding or failure of the ulcer to heal necessitated surgical intervention in six patients.

High peptic stricture of the oesophagus

Fifty-seven patients with high peptic stricture and the lower oesophagus lined by columnar epithelium are considered from the clinical point of view. Information from 115 cases of low stricture is introduced for comparison. The average age of adult patients was 62 years with a sex incidence of 36 females to 21 males. There is little difference between the symptoms of high and low strictures. Radiologically, the majority of high strictures are short and smooth but other types are illustrated. Carcinoma and congenital mid-oesophageal web are considered in the differential diagnosis. There was an associated duodenal ulcer in 10% of cases. In six patients, a high stricture developed soon after an abdominal operation or period of recumbency. Two patients are illustrated showing the process of stricture formation. Four patients are described who had gastric-lined oesophagus but no ulceration of stricture. One patient had a Barrett ulcer in addition to a high stricture. A patient is described in whom the mucosa of the lower oesophagus appeared to be replaced by jejunal mucosa following oesophagojejunostomy. One patient is illustrated in whom a stricture was seen to ascend the oesophagus over a period of six years. Thirty-three patients were treated by dilatation and 24 by operation. Hernial repair is an effective form of treatment. Of 19 patients treated in this way, significant dysphagia persisted in two and slight dysphagia in one. The clinical findings are discussed in relation to the origin of columnar epithelium in the oesophagus.

A clinical and radiological review of 204 hiatal hernia operations

Two hundred and four patients with reflux oesophagitis and hiatal hernia were operated on by a modified Allison's technique and followed up for one to 10 years. To avoid surgical bias, the clinical and radiological findings were assessed by the co-author, a radiologist. Ages, type of hernia, symptoms, coexisting pathology, and operative technique are described. The late follow-up includes an assessment of patients' opinions of their operation and residual symptoms and a review of the radiological findings. The management of 25 patients with fibrous strictures is described. Factors preventing reflux are discussed. Current operative procedures for reflux oesophagitis are reviewed. In this series of 204 cases, five patients, that is 2·5%, were surgical failures. They were all dissatisfied with their operation and their symptoms had not improved; radiologically three of them showed reflux or an irreducible hiatal hernia. This failure rate is not considered unreasonable and the modified Allison's procedure is therefore recommended for patients with reflux oesophagitis.

The assessment of oesophagitis in hiatus hernia patients

The incidence of oesophagitis has been determined in 108 patients with sliding hiatus hernias using endoscopic, histological, and radiological criteria. Particular consideration has been given to the relationship between inflammatory disease and clinical symptoms. All the patients were attending a thoracic surgical clinic and the spectrum of disease encountered was fairly severe; over half of the cases had established strictures when first seen. The incidence of oesophagitis based on endoscopic evidence was 76·9%, while inflammatory change was noted on biopsy in 56·2% and at barium swallow in 58·3% of the patients. Oesophagoscopy proved to be the most satisfactory method of assessment; biopsy specimens were either inadequate or correlated poorly with other criteria while barium swallow was of diagnostic value only in severe oesophagitis. The main symptoms were pain, heartburn with regurgitation, dysphagia, and bleeding. Dysphagia was common due to the preponderance of patients with strictures, while obvious bleeding was very uncommon. Endoscopic oesophagitis was found in 75% of the patients with specific retrosternal pain and in 60% of those with heartburn and regurgitation. The inability to equate heartburn with oesophagitis is emphasized. The incidence of inflammatory change in patients with dysphagia was 87·2%; nearly all the cases in this group showed stricture formation.

An appraisal of the methods for treating hiatus hernia and its complications

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