Can a hiatal hernia cause iron deficiency anemia?

Hiatal Hernia as a Cause of Iron Deficiency Anemia

Yes, a hiatal hernia can cause iron deficiency anemia through chronic occult blood loss, particularly in large hiatal hernias with Cameron lesions. This association is well-documented but often overlooked in clinical practice.

Mechanism and Prevalence

Hiatal hernias, especially large ones, can lead to iron deficiency anemia (IDA) through several mechanisms:

• Cameron lesions: These are linear gastric erosions or ulcers that occur at the diaphragmatic impression where the stomach herniates through the diaphragm 1, 2
• Chronic mechanical trauma: The stomach rubbing against the diaphragm at the "waist" of the hernia causes mucosal injury
• Slow, chronic blood loss: Often occult bleeding without visible hematemesis or melena

The prevalence of hiatal hernia as a cause of IDA is significant:

• Found in 5-9.2% of patients with iron deficiency anemia 1, 3
• More common in females (75% of cases) 1
• Often presents with anemia (62%) rather than overt GI bleeding (36%) 1

Clinical Presentation and Diagnosis

Patients with hiatal hernia-related IDA typically present with:

• Symptoms of anemia (fatigue, dyspnea, reduced exercise tolerance)
• Often minimal or no gastrointestinal symptoms
• Laboratory findings consistent with iron deficiency

Important diagnostic considerations:

• Cameron lesions are frequently missed on initial endoscopy, with up to 69% of patients undergoing one or more endoscopies before diagnosis 1
• Cameron erosions are visible in only about 33-50% of cases 4, 3
• The absence of visible erosions does not rule out hiatal hernia as the cause of IDA 4

Management Approach

According to current guidelines, the management of hiatal hernia-related IDA should follow these steps:

1. Confirm iron deficiency:

   • Serum ferritin is the most useful marker 5
   • Transferrin saturation can help if false-normal ferritin is suspected 5

2. Endoscopic evaluation:

   • Upper GI endoscopy should be performed in all men and postmenopausal women with IDA 5
   • Pay special attention to the diaphragmatic hiatus area
   • Multiple views may be needed to identify Cameron lesions

3. Treatment options:

   • Iron replacement therapy: Essential for all patients to correct anemia 5
   • Acid suppression: Proton pump inhibitors (PPIs) promote healing of Cameron lesions 2, 3
   • Surgical repair: Consider in transfusion-dependent cases or when medical therapy fails 6

Effectiveness of Treatment

Research shows that:

• PPI therapy alone can be effective in preventing recurrence of anemia 3
• In one study, surgery plus PPI was no better than PPI alone for preventing recurrence 3
• However, surgical repair has been shown to cure anemia in transfusion-dependent cases 6

Important Clinical Considerations

• Hiatal hernia should be considered in the differential diagnosis of IDA even when no Cameron lesions are visible 4, 3
• Many patients are already on PPI therapy when diagnosed, suggesting that higher doses or surgical intervention may be needed in refractory cases 1
• Repeated unnecessary endoscopies can be avoided by early consideration of hiatal hernia as a cause of IDA 6
• In patients with recurrent or refractory IDA, wireless capsule endoscopy may be needed to exclude other small bowel causes 5

Follow-up

• Monitor hemoglobin and iron studies to ensure resolution of anemia
• Long-term iron therapy is typically required for maintenance 2
• Consider follow-up endoscopy to assess healing of Cameron lesions in patients treated medically

By recognizing hiatal hernia as a potential cause of iron deficiency anemia, particularly in cases where other common causes have been excluded, clinicians can avoid diagnostic delays and implement appropriate treatment strategies.