Overview
Definition:
Cameron ulcers are linear or serpiginous mucosal defects located within a paraesophageal or sliding hiatal hernia sac, often on the crest of mucosal folds
They are a recognized cause of chronic or acute gastrointestinal bleeding, particularly in elderly patients with significant hernias
The bleeding can range from occult to massive hemorrhage.
Epidemiology:
The reported incidence of Cameron ulcers varies widely, with some studies suggesting they are found in up to 75% of patients with large hiatal hernias
They are more common in older individuals and those with associated conditions like iron deficiency anemia
The precise prevalence of significant bleeding from these ulcers is less well-defined.
Clinical Significance:
Cameron ulcer bleeding is clinically significant due to its potential to cause severe anemia, requiring urgent intervention
It poses a diagnostic challenge, as standard upper endoscopy may miss these lesions if the hernia sac is not fully intubated
Prompt recognition and appropriate surgical or endoscopic management are crucial to prevent morbidity and mortality associated with significant hemorrhage and chronic blood loss.
Clinical Presentation
Symptoms:
Hematemesis, often bright red or coffee-ground
Melena, presenting as dark, tarry stools
Symptoms of chronic iron deficiency anemia: fatigue, pallor, dyspnea on exertion, palpitations
Epigastric pain or discomfort
Heartburn or reflux symptoms, often exacerbated by meals or lying down
Nausea or vomiting
In severe cases, symptoms of hypovolemic shock: dizziness, syncope, hypotension, tachycardia.
Signs:
Pallor of the conjunctivae and mucous membranes
Tachycardia and hypotension in cases of active or significant bleeding
Abdominal tenderness, particularly in the epigastric region
Distended abdomen in rare cases of massive hemorrhage
Evidence of anemia on physical examination.
Diagnostic Criteria:
Diagnosis is primarily made by endoscopy, which should specifically attempt to visualize the hernia sac
Findings include linear or serpiginous ulcers within the hiatal hernia
Associated findings may include evidence of chronic blood loss (e.g., iron deficiency anemia)
The diagnosis is confirmed when bleeding is identified at the ulcer site during endoscopy or surgery, and other causes of gastrointestinal bleeding have been excluded.
Diagnostic Approach
History Taking:
Detailed history of bleeding episodes: frequency, volume, color of blood
Duration and severity of anemia symptoms
History of gastroesophageal reflux disease (GERD), hiatal hernia, or prior gastrointestinal surgery
Medications: NSAIDs, anticoagulants, antiplatelets
Significant comorbidities: cardiac, pulmonary, renal disease
Family history of gastrointestinal pathology.
Physical Examination:
A thorough abdominal examination, assessing for tenderness, masses, or organomegaly
Auscultation for bowel sounds
Rectal examination to assess for melena
Examination of skin and mucous membranes for pallor
Assessment of hemodynamic status: vital signs, capillary refill.
Investigations:
Complete blood count (CBC) to assess for anemia (hemoglobin, hematocrit, MCV, MCH)
Iron studies (serum iron, ferritin, transferrin saturation) to confirm iron deficiency
Coagulation profile (PT, INR, aPTT) if bleeding is active or patient is on anticoagulants
Upper gastrointestinal endoscopy (EGD) with careful intubation of the hernia sac
biopsy of any suspicious lesions
Barium swallow can identify hiatal hernia but is less sensitive for ulcer detection
CT angiography or visceral angiography may be used in cases of active, massive bleeding not controlled by initial measures.
Differential Diagnosis:
Peptic ulcer disease (gastric or duodenal)
Esophagitis
Mallory-Weiss tear
Gastric erosions
Dieulafoy's lesion
Vascular malformations
Malignancy (gastric or esophageal)
Variceal bleeding
Hemobilia
Meckel's diverticulum bleeding.
Management
Initial Management:
Hemodynamic stabilization: intravenous fluids, blood transfusion if necessary
Correction of coagulopathy if present
NPO (nil per os)
Nasogastric tube insertion for decompression and monitoring of ongoing bleeding
Acid suppression therapy with proton pump inhibitors (PPIs) at high doses.
Medical Management:
High-dose intravenous PPI therapy (e.g., pantoprazole 40 mg IV every 12 hours, or 8 mg/hour infusion) to reduce gastric acid production and promote ulcer healing
Treatment of iron deficiency anemia with oral or intravenous iron supplementation
Transfusion of packed red blood cells to maintain hemoglobin levels above 7-8 g/dL, or higher in patients with significant comorbidities.
Surgical Management:
Surgical indications include persistent or recurrent bleeding despite endoscopic and medical management, large or actively bleeding ulcers, hemodynamic instability, or failure to visualize the ulcer via endoscopy
The definitive treatment often involves repair of the hiatal hernia and excision or plication of the ulcer within the hernia sac
Options include: Transabdominal or transthoracic repair of the hiatal hernia with excision of the Cameron ulcer
Laparoscopic approach for hernia repair with ulcer management
Antrectomy with truncal vagotomy or selective vagotomy if associated with severe peptic ulcer disease refractory to medical therapy
In some cases, stapled gastroplication may be performed without direct ulcer excision if the ulcer is small and quiescent.
Supportive Care:
Continuous monitoring of vital signs and urine output
Serial hemoglobin and hematocrit measurements
Electrolyte balance monitoring
Adequate pain control
Nutritional support, often initiated after the acute bleeding has subsided
Early mobilization to prevent deep vein thrombosis and pulmonary complications.
Complications
Early Complications:
Recurrent bleeding, often requiring repeat endoscopy or surgery
Hypovolemic shock
Hemorrhagic shock
Anemia
Gastric outlet obstruction from edema or inflammation
Pneumonia
Wound infection (following surgery)
Deep vein thrombosis/Pulmonary embolism.
Late Complications:
Recurrence of the hiatal hernia
Esophagitis or GERD
Nutritional deficiencies due to malabsorption or reduced intake
Adhesions and bowel obstruction (post-surgery)
Stricture formation at the repair site.
Prevention Strategies:
Aggressive management of hiatal hernias, especially in symptomatic patients or those with evidence of bleeding
Thorough endoscopic examination of the hernia sac in patients with unexplained GI bleeding
Early surgical intervention for persistent bleeding
Careful surgical technique to minimize tissue trauma and ensure secure hernia repair
Postoperative vigilance for signs of bleeding or recurrence.
Prognosis
Factors Affecting Prognosis:
Severity of bleeding and hemodynamic stability at presentation
Presence of comorbidities
Adequacy and promptness of intervention (endoscopic or surgical)
Size and depth of the ulcer
Success of hiatal hernia repair
Patient's adherence to medical management and follow-up.
Outcomes:
With timely and appropriate management, the prognosis for Cameron ulcer bleeding is generally good
Most patients respond well to PPI therapy, endoscopic hemostasis, or surgery
However, recurrent bleeding can occur, particularly if the hiatal hernia is not adequately addressed
Long-term outcomes depend on successful hernia repair and management of associated reflux symptoms.
Follow Up:
Regular follow-up appointments are recommended to monitor for recurrence of symptoms, anemia, or bleeding
Endoscopic surveillance may be indicated depending on the severity of the initial presentation and the success of treatment
Patients should be advised on lifestyle modifications to reduce reflux symptoms and encouraged to adhere to PPI therapy and iron supplementation as prescribed.
Key Points
Exam Focus:
Cameron ulcers are located in hiatal hernias
They are a common cause of anemia in the elderly
Endoscopy requires careful intubation of the hernia sac for visualization
Surgical repair of the hiatal hernia is often the definitive treatment for recurrent or severe bleeding.
Clinical Pearls:
Always suspect Cameron ulcers in elderly patients with unexplained iron deficiency anemia and a history of hiatal hernia or reflux
Aggressively intubate the hernia sac during endoscopy
Consider operative management for persistent bleeding to address both the ulcer and the underlying hernia.
Common Mistakes:
Failure to intubate the hernia sac during endoscopy, leading to missed diagnosis
Delaying surgical intervention in cases of significant or recurrent bleeding
Inadequate management of the hiatal hernia, leading to recurrence of bleeding or symptoms.