S3592 Cameron Lesions Resulting in Occult GI Bleeding and Anemia

Abstract

Introduction: Cameron lesions are ulcerations which develop in the sac of hiatal hernias at the diaphragmatic hiatus. They occur in about 3-12% of patients with hiatal hernias. The overall prevalence of Cameron lesions in all patients is less than 1%. Nonsteroidal anti-inflammatory drugs (NSAIDs) are also associated with the development of Cameron lesions. These lesions can present with either occult or overt gastrointestinal bleeding. They are often missed on routine endoscopy given their diminutive size and inconspicuous location which requires thorough antegrade and retrograde examination. We describe a case of a woman with a large hiatal hernia and Cameron lesions with resulting symptomatic iron deficiency anemia. Case Description/Methods: A 50-year-old woman with obstructive sleep apnea, chronic lymphedema, and major depressive disorder underwent routine esophagogastroduodenoscopy (EGD) due to several months of dysphagia and odynophagia. She was found to have grade B esophagitis and a large hiatal hernia with multiple Cameron lesions. Proton pump inhibitor was prescribed. A few months later, patient presented to clinic with orthostatic dizziness and weakness; Hemoglobin (Hgb) was 6.0 mg/dL (previously normal two years prior). She was admitted to the hospital and received red blood cell transfusions with an appropriate response in Hgb and oral iron supplementation; anti-reflux medications were continued on discharge. After one year of strict adherence to anti-reflux regimen and iron supplementation, her hemoglobin levels normalized. Repeat EGD was obtained eighteen months later due to continued dysphagia and odynophagia and showed resolution of Cameron lesions and esophagitis but progression in the size of the hiatal hernia. She was referred to a general surgeon and underwent laparascopic para-esophageal repair and partial fundoplication with resolution of her symptoms. Discussion: Cameron lesions may cause overt and occult gastrointestinal bleeding with resulting iron deficiency anemia. These lesions have been mostly described in association with large hiatal hernias and routine NSAID use. Medical treatment with a proton pump inhibitor and discontinuation of NSAIDs is usually sufficient to treat these ulcerations but some patients may require endoscopic or surgical management in severe cases. Gastroenterologists should give special attention to the mucosa of the diaphragmatic hiatus in patients with a hiatal hernia and suspicion for gastrointestinal bleeding to evaluate for Cameron lesions.Figure 1.: Cameron lesions seen on retrograde view during endoscopy.