Can a large hiatal (esophageal) hernia cause iron deficiency anemia?

Large Hiatus Hernias Can Cause Iron Deficiency Anemia

Yes, a large hiatal hernia can cause iron deficiency anemia through chronic occult blood loss from gastric erosions at the diaphragmatic impression. 1, 2, 3

Mechanism of Iron Deficiency Anemia in Hiatal Hernias

Large hiatal hernias can lead to iron deficiency anemia through several mechanisms:

1. Cameron lesions: Linear gastric erosions or ulcers that develop at the "waist" or neck of the hernia where the stomach rubs against the diaphragm 1, 3
2. Chronic occult bleeding: These lesions cause slow, persistent blood loss that often goes undetected 2
3. Mechanical trauma: Repeated movement of the herniated stomach through the diaphragmatic hiatus causes mucosal injury 1

Clinical Presentation and Diagnosis

Patients with large hiatal hernias and iron deficiency anemia typically present with:

• Anemia symptoms (fatigue, weakness, dyspnea) rather than reflux symptoms 1, 2
• Iron deficiency anemia without obvious source of bleeding 2
• Laboratory findings consistent with iron deficiency (low ferritin, low transferrin saturation) 4

Diagnostic Approach:

1. Upper endoscopy: Essential but Cameron lesions may be missed on initial examination (only identified in 50% of cases at first endoscopy) 2, 3
2. Colonoscopy: Necessary to exclude colonic sources of blood loss 4
3. Repeat endoscopy: May be required if initial endoscopy is negative but suspicion remains high 3
4. Capsule endoscopy: Can be helpful in identifying Cameron lesions missed on conventional endoscopy 3

Management Options

Treatment approaches for hiatal hernia-associated iron deficiency anemia include:

1. Medical management:

   • Iron replacement therapy (oral or IV) to correct anemia 1, 2
   • Acid suppression with proton pump inhibitors or H2 antagonists to promote healing of erosions 1, 3
   • Studies show H2 antagonists promote healing of erosions in approximately 64% of cases 1

2. Surgical management:

   • Laparoscopic repair of hiatal hernia for refractory cases 5, 6
   • Surgical repair has shown excellent outcomes:
     • Resolution of anemia in 73.7% of patients 5
     • Discontinuation of iron supplements in 94.5% of patients 5
     • No recurrence of anemia after median follow-up of over 2 years 6
     • Significant improvement in quality of life measures 5

Clinical Pearls and Pitfalls

• Overlooked diagnosis: Cameron lesions are frequently missed during routine endoscopy and should be specifically looked for in patients with unexplained iron deficiency anemia 2, 3
• Recurrent anemia: In patients with known hiatal hernias and recurrent iron deficiency anemia, Cameron lesions should be high on the differential diagnosis 3
• Complete evaluation: Even when a hiatal hernia is identified, a complete GI evaluation (including colonoscopy) is still recommended to exclude other sources of blood loss 4
• Surgical consideration: Consider surgical repair in patients with transfusion-dependent anemia or those who fail medical management 2, 5, 6

Conclusion

Large hiatal hernias represent an important and potentially underdiagnosed cause of iron deficiency anemia. The British Society of Gastroenterology guidelines recognize GI blood loss as the most common cause of iron deficiency anemia in men and postmenopausal women 4, and hiatal hernias with Cameron lesions should be considered in the differential diagnosis of unexplained iron deficiency anemia.