Severe Iron Deficiency Anemia Caused by Hiatal Hernia

Abstract

Purpose: Patients with hiatal hernias are usually asymptomatic or have only vague, intermittent symptoms such as epigastric pain, nausea and reflux symptoms. In this report, we describe two children with a hiatal hernia who initially presented with severe, iron deficiency anemia. Results: The first patient was a 20 month old boy, born prematurely at 26 weeks. At 18 months, he had 2 episodes of hematemesis. He had a hemoglobin of 5.8, a hematocrit of 19.8, WBC of 12,200, and platelets of 570,000. Serum iron was 36 and TIBC 452, with a transferrin saturation of 8%. Stool for occult blood was intermittently positive. He was transfused with packed red blood cells. An upper gastrointestinal series showed a large hiatal hernia that was later confirmed by upper endoscopy. The endoscopy and biopsies showed evidence of reflux esophagitis. A pH study showed significant reflux. The patient underwent hiatal hernia repair and Nissen fundoplication at 24 months. Since the surgery his hemoglobin and hematocrit have remained normal for 14 months. The second patient was a 6 year old boy referred to Pediatric Hematology and Oncology with a hemoglobin of 6.0 and a hematocrit of 18.9. He had platelets of 357,000and a WBC of 11,100. Serum iron was 12, total iron binding capacity was 487, with a transferrin saturation of 2%. He had a 2 day history of abdominal pain and vomiting. An upper GI series showed a hiatal hernia and upper endoscopy showed severe erosions of the gastric fundus. He had an exploratory laparotomy and hiatal hernia repair, suture repair of the esophageal hiatus and lesser curvature anterior gastropexy. Since the surgery his hemoglobin and hematocrit have remained normal for 7 months. Conclusions: Severe iron deficiency anemia may be associated with hiatal hernia. In our first patient, the anemia may have resulted from the reflux esophagitis secondary to the hiatal hernia. In our second patient the anemia was due to gastric erosions that may have resulted from prolapse of the gastric fundus into the esophagus. Hiatal hernia should be considered in patients with severe iron deficiency anemia.