What are Cameron lesions?

Cameron Lesions: Definition, Diagnosis, and Management

Cameron lesions are linear erosions or ulcers that develop on the crests of gastric mucosal folds at the diaphragmatic impression in patients with hiatal hernias, representing an important but often overlooked cause of gastrointestinal bleeding and iron deficiency anemia. 1, 2

Clinical Characteristics

• Epidemiology:

  • Found in approximately 5.2% of patients with hiatal hernias who undergo upper endoscopy 2
  • More common in larger hiatal hernias 2
  • Higher prevalence in females (75% of cases) 3
  • Can occur at any age but more commonly found in older adults

• Presentation:

  • Chronic iron deficiency anemia (62% of cases) 3
  • Overt gastrointestinal bleeding (36% of cases) 3
  • Acute upper GI bleeding (can be life-threatening in up to one-third of cases) 2
  • Often asymptomatic and discovered incidentally during endoscopy

Pathophysiology

Cameron lesions are thought to develop through multiple mechanisms:

1. Mechanical trauma: Repeated movement of the stomach in and out of the thoracic cavity causes friction at the diaphragmatic hiatus 2
2. Ischemic injury: Compression of the herniated portion of the stomach at the diaphragmatic hiatus leads to compromised blood flow 2
3. Acid-related mucosal injury: Acid exposure contributes to mucosal damage 2

Diagnostic Challenges

Cameron lesions are frequently missed during endoscopic evaluation:

• Up to 69% of patients undergo one or more previous upper endoscopies before the diagnosis is made 3
• They are considered "commonly overlooked lesions" in the upper GI tract 4
• The diagnosis should be suspected in any patient with:
  • Hiatal hernia (especially large)
  • Unexplained iron deficiency anemia
  • Overt or occult GI bleeding

Endoscopic Features

• Linear erosions or ulcers located at the diaphragmatic impression
• Usually found at the crest of gastric mucosal folds in the neck of the hiatal hernia
• Often multiple rather than solitary (in about two-thirds of cases) 2
• May be accompanied by signs of chronic gastritis or reflux esophagitis

Management Approaches

1. Medical therapy:

   • Proton pump inhibitors (PPIs) are the mainstay of treatment 3
   • Iron supplementation for anemia correction 3
   • Note: 60% of patients were already on PPI therapy when diagnosed, suggesting standard doses may be insufficient 3

2. Endoscopic therapy:

   • Endoscopic hemostasis for actively bleeding lesions (required in approximately 10% of cases) 3

3. Surgical intervention:

   • Hiatal hernia repair should be considered, especially in:
     • Patients with recurrent bleeding despite medical therapy
     • Cases with persistent anemia despite iron supplementation
     • Large symptomatic hiatal hernias
   • Approximately one-third of patients ultimately require surgical repair 3

Clinical Course and Outcomes

• Recurrence rate of approximately one-third in patients treated medically 2
• Complications occur in about 17% of medically treated patients with long-term follow-up 2
• Most common complications:
  • Acute upper GI bleeding (6.3%)
  • Persistent/recurrent iron deficiency anemia (8.3%)

Important Clinical Considerations

• Cameron lesions should be specifically looked for during endoscopy in any patient with a hiatal hernia and unexplained anemia
• Careful examination of the gastric mucosa at the level of the diaphragmatic impression is essential
• Consider this diagnosis in patients with recurrent or persistent anemia despite negative routine endoscopic evaluations
• Long-term management with higher-dose PPI therapy or surgical repair may be necessary for definitive treatment

Cameron lesions remain an important and potentially overlooked diagnosis that should be considered in the differential for patients with hiatal hernias presenting with iron deficiency anemia or gastrointestinal bleeding.