How should I diagnose and manage Cameron erosions associated with a large sliding hiatal hernia that cause iron‑deficiency anemia and upper abdominal discomfort?

Cameron Erosions: Diagnosis and Management

Immediate Diagnostic Approach

Cameron erosions are commonly overlooked linear gastric ulcers or erosions located on mucosal folds at the diaphragmatic impression in patients with large hiatal hernias, and they require careful endoscopic examination with high-dose PPI therapy and consideration for surgical repair. 1, 2

Key Diagnostic Features

• Cameron lesions are frequently missed during routine upper endoscopy, with up to 69% of patients undergoing one or more previous endoscopies before diagnosis is finally achieved 2
• The lesions appear as linear erosions or ulcers positioned on the crests of mucosal folds at the level of the diaphragmatic impression within a large hiatal hernia (typically >3-4 cm) 3, 4, 5
• They are specifically identified as a commonly overlooked upper GI lesion in the AGA guidelines on obscure GI bleeding 1

Essential Diagnostic Workup

Laboratory confirmation of iron deficiency:

• Obtain serum ferritin (diagnostic if <15 μg/L, concerning if <45 μg/L) and transferrin saturation (<16% confirms iron deficiency) 6
• Complete blood count showing microcytic hypochromic anemia 3, 4

Mandatory screening tests:

• Celiac disease screening (tissue transglutaminase antibodies or small bowel biopsy during endoscopy), as it accounts for 3-5% of IDA cases 1, 6, 7
• Urinalysis to exclude urinary tract bleeding 6, 7

Endoscopic evaluation:

• Perform careful upper endoscopy with specific attention to the hiatal hernia sac and mucosal folds at the diaphragmatic level, as these lesions are easily overlooked 8, 2
• Consider repeat endoscopy or capsule endoscopy if initial examination is negative but clinical suspicion remains high 8
• Complete bidirectional endoscopy (colonoscopy in addition to EGD) is mandatory because dual pathology occurs in 10-15% of patients 1, 7

Management Strategy

Medical Therapy (First-Line)

Initiate high-dose proton pump inhibitor therapy immediately:

• High-dose PPI therapy is the mainstay of medical treatment 3, 8, 5
• Start oral iron supplementation (100-200 mg elemental iron daily) without waiting for endoscopic evaluation 6, 7
• Continue iron therapy for 3 months after hemoglobin normalization to replenish iron stores 1, 7

Critical Management Caveat

Standard-dose PPI therapy is often insufficient, as approximately 60% of patients in whom Cameron lesions are diagnosed are already receiving standard PPI therapy when the diagnosis is made, suggesting that either long-term high-dose PPI or surgical intervention is required 2

Surgical Intervention

Consider laparoscopic hiatal hernia repair with fundoplication when:

• Medical therapy fails to control bleeding or anemia recurs 3, 4
• Patient becomes transfusion-dependent 2
• Large hiatal hernia (>5 cm) with recurrent symptoms 4

The surgical approach typically involves hiatal hernia repair with mesh and Toupet or Nissen fundoplication 3, 4

Adjunctive Measures

• Stop NSAIDs and aspirin immediately if the patient is taking them 7
• Blood transfusion may be required in approximately one-third of cases with severe anemia 2
• Endoscopic hemostasis is performed in approximately 10% of cases with active bleeding 2

Monitoring and Follow-Up

• Monitor hemoglobin and MCV at 3-month intervals for one year, then annually 1
• If hemoglobin and MCV cannot be normalized despite adequate therapy, reconsider further small bowel evaluation with capsule endoscopy 1, 7
• Follow-up studies demonstrate this approach is safe provided dietary deficiency is corrected and hemoglobin is monitored 1

Common Pitfalls to Avoid

• Never assume a single upper GI lesion explains the anemia—complete lower GI evaluation due to 10-15% dual pathology rate 1, 7
• Do not accept superficial gastritis, mild esophagitis, or small erosions as the sole cause of iron deficiency anemia without carefully examining for Cameron lesions in the hiatal hernia sac 1, 2
• Avoid stopping at standard-dose PPI therapy—these patients often require high-dose or long-term therapy, or surgical correction 2
• Do not delay iron supplementation while awaiting endoscopic evaluation 6, 7