What is the best course of treatment for a patient with a Cameron's ulcer within a hernia sac, considering potential complications and underlying gastrointestinal issues?

Cameron's Ulcer Within Hernia Sac: Treatment Approach

Immediate Management Strategy

For Cameron ulcers presenting with acute life-threatening bleeding, endoscopic hemostasis is the first-line intervention in hemodynamically stable patients, but surgical intervention should not be delayed in unstable patients or when endoscopic control fails. 1, 2

Hemodynamic Assessment and Initial Intervention

• Hemodynamically stable patients (MAP ≥65 mmHg, HR <94 bpm) should undergo urgent upper endoscopy as the primary diagnostic and therapeutic modality 1
• Hemodynamically unstable patients not responding to aggressive resuscitation require immediate surgical exploration without delay for endoscopic attempts 1
• Transfusion support with packed red blood cells and intravenous proton pump inhibitor infusion should be initiated immediately 3

Endoscopic Management Approach

• Perform urgent esophagogastroduodenoscopy with meticulous inspection of mucosal folds along the neck of the hernia sac, as Cameron lesions are frequently overlooked during routine endoscopy 4, 5
• Endoscopic hemostatic techniques (clips, thermal coagulation, injection therapy) should be attempted in stable patients 1
• Critical pitfall: Cameron ulcers are often multiple (present in two-thirds of cases) rather than solitary, requiring complete visualization of the entire hernia sac 4
• If endoscopic hemostasis fails after one attempt in a stable patient, proceed directly to angiography with embolization if available, or surgical intervention 1

Angiographic Intervention

• In stable patients with ongoing bleeding after failed endoscopy, angio-CT followed by angioembolization is recommended when technical skills and equipment are available 1
• Do not delay surgical exploration if angioembolization fails or is unavailable 1

Surgical Management

Indications for Surgery

Surgical intervention is mandatory in the following scenarios:

• Hemodynamic instability with ongoing bleeding despite resuscitation 1
• Failed endoscopic hemostasis (inability to achieve hemostasis after endoscopic attempt) 1
• Failed angioembolization 1
• Recurrent bleeding after initial endoscopic control 2

Surgical Technique Selection

For Cameron ulcers requiring surgery, the approach depends on ulcer characteristics and patient stability:

Minimally Invasive Approach (Preferred for Stable Patients)

• Single-incision laparoscopic transgastric underrunning and closure is a suitable minimally invasive option for hemostasis and definitive treatment of Cameron ulcers 6
• This technique involves gastrotomy, direct visualization of the ulcer(s), and underrunning sutures for hemostasis 6
• Allows for concurrent hiatal hernia repair in a staged fashion after patient stabilization 6

Atypical Gastric Resection

• For large Cameron ulcers (≥2 cm) or when tissue is too friable for primary repair, minimally invasive atypical gastric resection combined with hiatal hernia repair should be performed 2
• Mandatory biopsy of all gastric ulcerations must be obtained to exclude malignancy (10-16% risk of gastric carcinoma in gastric perforations/ulcers) 7

Open Surgery

• Reserved for hemodynamically unstable patients or when laparoscopic skills/equipment are unavailable 1
• Direct gastrotomy with underrunning of bleeding vessels and ulcer closure 2

Damage Control Considerations

• In patients with severe septic shock, hemodynamic instability, or severe metabolic acidosis, focus on controlling hemorrhage with the simplest effective technique rather than attempting definitive hernia repair 1, 6
• Definitive hiatal hernia repair can be performed in a staged fashion (typically 7-10 days later) once the patient is stabilized 6

Definitive Hernia Management

Timing of Hernia Repair

• For acute bleeding: Control hemorrhage first; stage hernia repair after hemodynamic stabilization (typically postoperative day 7-10) 6
• For chronic anemia without active bleeding: Combined ulcer treatment and hernia repair can be performed in a single operation 3

Surgical Technique for Hernia Repair

• Laparoscopic hiatal hernia repair with mesh reinforcement and fundoplication (Toupet or Nissen) is the standard approach 3
• Mesh reinforcement reduces recurrence rates in large hiatal hernias 3
• Fundoplication addresses the underlying gastroesophageal reflux that contributes to Cameron ulcer formation 3

Medical Management Components

Acute Phase

• High-dose intravenous proton pump inhibitor therapy (pantoprazole 80 mg bolus followed by 8 mg/hour infusion) 3
• Iron replacement therapy for anemia correction 3, 4
• H. pylori testing and eradication if positive, as this is a major etiologic factor 7

Long-Term Management

• Strict NSAID avoidance is mandatory, as NSAIDs are a primary etiologic factor and significantly increase recurrence risk 7
• Smoking cessation is essential 7
• Long-term proton pump inhibitor therapy 4, 5

Recurrence Risk and Follow-Up

• With medical therapy alone, approximately one-third of patients experience recurrence of Cameron lesions 4
• 17% develop complications including acute upper GI bleeding (6.3%) or persistent iron deficiency anemia (8.3%) with medical management alone 4
• Definitive hiatal hernia repair is necessary to prevent recurrence, as medical therapy alone has high failure rates 4, 2

Critical Pitfalls to Avoid

• Do not overlook multiple lesions: Examine the entire hernia sac circumferentially, as two-thirds of cases have multiple Cameron ulcers 4
• Do not delay surgery in unstable patients attempting repeated endoscopic interventions—every hour of delay increases mortality by 2.4% in bleeding peptic ulcer disease 1, 8
• Do not omit biopsy of gastric ulcerations to exclude malignancy 7
• Do not rely on medical therapy alone for definitive management—hernia repair is necessary to prevent recurrence 4, 2
• Do not attempt complex definitive hernia repair in hemodynamically unstable patients—control bleeding first, repair hernia later 1, 6