Does Size Matter? Cameron Lesions Associated With a Small Hiatal Hernia

Abstract

Introduction: Cameron lesions are mucosal erosions or ulcers found at the level of the diaphragmatic hiatus within the hiatal hernia. Usually asymptomatic, Cameron lesions are found incidentally on upper endoscopy. However, they can be a source of obscure gastrointestinal bleeding. Cameron lesions have been reported to be associated mainly with large hiatus hernias and NSAIDs use. Here in, we present a unique case of gastrointestinal bleeding secondary to a Cameron ulcer associated with a small subcentimeter hiatus hernia. Case report: A 76-year-old woman with medical history of hypertension, sarcoidosis, prior cerebral vascular accidents, coronary artery disease presented with complaints of dark watery stools, multiple episodes of coffee ground emesis and mild epigastric abdominal pain. Physical examination revealed a soft abdomen with normal bowel sounds and mild tenderness in the epigastrium. Initial laboratory tests demonstrated hemoglobin of 10.3 g/dL, blood urea nitrogen and creatinine of 32 mg/dL and 1.5 mg/dL respectively. Esophagogastroduodenoscopy (EGD) revealed a small hiatal hernia with three linear clean based non-bleeding ulcers, consistent with Cameron ulcers (Figure 1&2). No gross lesions were noted in the remainder of the stomach or the duodenum.Figure: Small hiatal hernia (blue arrow) with three linear clean based non-bleeding ulcers (yellow arrow), consistent with Cameron ulcers.Figure: Small hiatal hernia (blue arrow) with three linear clean based non-bleeding ulcers (yellow arrow), consistent with Cameron ulcers.Discussion: Cameron lesions have a higher prevalence in cases of large hiatal hernias. An estimated 3.3-5% of individuals with hiatus hernias are said to have Cameron lesions. Prevalence however increases to 13.7% among patients with large (> 5cm) hiatus hernia. Cameron lesions are caused by a combination of various factors acting at the level of the diaphragmatic hiatus. Mechanical injury from the contractility of the respiratory diaphragm, mucosal damage from exposed esophageal mucosa to the caustic gastric acid and ischemia from mucosal erosions are thought to result in Cameron lesions. The treatment of Cameron lesions is mainly medical therapy with proton pump inhibitors. In patients with overt bleeding, there may be a need for endoscopic intervention with hemostasis clips coupled with medical therapy. Conclusion: Cameron lesions have a higher prevalence in large (>5cm) hiatus hernias. However, they can rarely be present in small sub-centimeter hiatus hernias and be a cause of an obscure GI bleeding. Therefore, a high index of suspicion for Cameron lesions is required at endoscopy- even in cases of small hiatus hernias in making a timely diagnosis and intervention.