Cameron Lesions

Cameron lesions are linear erosions or ulcers on the mucosal folds of a hiatal hernia at the diaphragmatic pinch, a cause of chronic iron deficiency anaemia.

• Found in 5% of patients with hiatal hernia undergoing endoscopy, and 0.2 to 3% of all upper endoscopies; prevalence rises with hernia size (over 5 cm) and age (mean 60 to 70 years).
• Mechanism: mechanical trauma from diaphragmatic contraction at the neck of the hernia, plus acid exposure, ischaemia and stasis.
• Associated: NSAID use, anticoagulants, Helicobacter pylori (minor role).
• Account for 3 to 5% of obscure upper gastrointestinal bleeding and 20% of cases with hiatal hernia and anaemia.
• Complications: chronic occult bleeding, transfusion dependence, rarely overt bleeding.

• Chronic iron deficiency anaemia (commonest presentation), fatigue, dyspnoea, palpitations.
• Overt haematemesis or melaena (10 to 20%).
• Reflux symptoms, epigastric pain, dysphagia; many asymptomatic.
• Coexisting large hiatal hernia, paraoesophageal hernia.

• Upper endoscopy with careful retroflexed view and examination of the hernia neck: linear erosions or ulcers (often multiple) on the crest of gastric folds at the diaphragmatic hiatus, covered with fibrin or clot.
• Barium swallow or CT shows the hiatal hernia size.
• Laboratory: full blood count, ferritin, iron studies, faecal occult blood.
• Exclude other sources: colonoscopy, capsule endoscopy, small bowel evaluation.
• H. pylori testing.

• Proton pump inhibitor: omeprazole 40 mg twice daily or esomeprazole 40 mg twice daily for 8 to 12 weeks, then maintenance 20 to 40 mg daily; healing in 80 to 90% of lesions.
• Iron replacement: ferrous sulfate 200 mg daily or IV iron (ferric carboxymaltose 15 mg/kg, maximum 1000 mg) if intolerance or poor response.
• Stop NSAIDs and review anticoagulants.
• Endoscopic therapy for active bleeding or visible vessels: epinephrine injection, haemoclips, thermal coagulation (bipolar).
• Surgical hernia repair (laparoscopic hiatal hernia repair with fundoplication) for persistent anaemia despite PPI, transfusion dependence, or large symptomatic hernia: resolution of anaemia in over 80%.
• Eradicate H. pylori if present.
• Monitor haemoglobin and ferritin every 3 months for a year; repeat endoscopy for recurrent bleeding.