Cameron lesions

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Cameron lesions
Other namesCameron ulcer
Specialty Gastroenterology

A Cameron lesion is a linear erosion or ulceration of the mucosal folds lining the stomach where it is constricted by the thoracic diaphragm in persons with large hiatal hernias. [1] The lesions may cause chronic blood loss resulting in iron deficiency anemia; less often they cause acute bleeding.

Contents

Treatment of anemia with Cameron lesions includes iron supplements and acid suppression by a proton-pump inhibitor (PPI). Surgical hernia repair is sometimes needed.

Signs and symptoms

Cameron lesions may lead to bleeding, and may be associated with heartburn or other symptoms of reflux. Generally, Cameron lesions do not cause pain.

Cause

A large hiatal hernia. Two x-rays from the same examination. On lying down (A) more stomach slides above the diaphragm than when upright (B) Note constriction of stomach at diaphragm level. Cameron lesions wiki (photos only)Xray.jpg
A large hiatal hernia. Two x-rays from the same examination. On lying down (A) more stomach slides above the diaphragm than when upright (B) Note constriction of stomach at diaphragm level.
Cameron lesions. A long linear erosion and smaller non-linear erosions on the crests of inflamed gastric folds at the level of the diaphragm. Cameron lesions wiki (photos only)Image.jpg
Cameron lesions. A long linear erosion and smaller non-linear erosions on the crests of inflamed gastric folds at the level of the diaphragm.

The diaphragm separates the chest from the abdomen. The esophagus (swallowing tube) passes through the hiatal opening in the diaphragm to reach the stomach. With a hiatal hernia, part of the stomach is displaced upwards into the chest (Figure 1). Large hiatal hernias may cause chronic gastrointestinal blood loss leading to iron deficiency anemia. One study in people with hernias showed mean blood loss of 15ml (a tablespoonful) per day in those with anemia, compared to 3 ml per day in those without anemia. [2] In one report 10% of 100 people investigated for iron deficiency anemia had a large hiatal hernia. [3] A 1967 review found that 20% of 1305 individuals having surgery for hiatal hernia were anemic. [4] Cameron in 1976 [5] compared 259 people with large hiatal hernias visible on chest x-ray with 259 controls without hernias. Present or past anemia, usually with proven iron deficiency, was found in 10.4% of those with hernias, significantly more than 0.4% of controls, p<0.001. Surgical hernia repair usually prevents anemia recurrence; in 2 large series, post-operative follow-up showed anemia had resolved in 71-92% of subjects. [6] [7] An isotope study showed correction of blood loss after hernia repair. [2] These findings showed that the hernia was the usual cause of the anemia.

Cameron lesions cause blood loss from hiatal hernias

Red, congested folds with blood on a Cameron lesion. Cameron lesions wiki (photos only)-2B.jpg
Red, congested folds with blood on a Cameron lesion.
After aspirating some air through the endoscope, this lesion was seen rubbing against opposite folds at the diaphragm level on respiration. Cameron lesions wiki (photos only)-2C.jpg
After aspirating some air through the endoscope, this lesion was seen rubbing against opposite folds at the diaphragm level on respiration.

Based on their surgical observations, Windsor and Collis in 1967 [4] proposed that blood loss was due to local trauma to the stomach where it rides to and fro in the hiatus on respiration. Boutelier et al. [8] noted on gastroscopy ulcers and erosions at the level of the neck of the hernia in individuals with acute and chronic bleeding, but no detailed description was given. Cameron and Higgins in 1986 [1] described linear gastric erosions, later called "Cameron lesions", in people with x-rays showing one-third or more of the stomach above the diaphragm. [9] [10] [11] [12] [13] [14] [15] (figure 1). Over 6 years, Cameron and Higgins studied 109 persons with large hiatal hernias, 55 with anemia and 54 without anemia, at esophagogastroduodenoscopy. Cameron lesions, often multiple, were found at or near the level where the herniated stomach was constricted by the diaphragm. The lesions were typically white, superficial, linear, and oriented along the crests of inflamed appearing mucosal folds (figure 2). Small amounts of blood were often seen on the lesions (Fig 3). Mucosal folds at the diaphragm level were often seen rubbing against each other on respiration (Fig 4). It was proposed that the lesions were caused by mechanical trauma at the level of constriction by the diaphragm [1] Cameron lesions were found in 42% of persons with anemia compared to 24% in those without anemia, a statistically significant difference, p<0.05. Spots of fresh or clotted blood were seen on the lesions in 25% of persons with anemia compared to 7% without anemia, also a significant difference, p<0.05. In the 109 persons in this study, 15 had reflux esophagitis, 11 had peptic ulcers, and 7 had Barrett's esophagus, but none of these findings correlated with anemia. Thus, in people with large hernias, Cameron lesions with evidence of slow bleeding were associated with iron deficiency anemia.

Acute bleeding from Cameron lesions, vomiting blood, or passing black bowel movements, is rare; in one report Cameron lesions were found in 3.8% of people presenting with anemia, but in only 0.2% of those with acute bleeding. [14] Small hernias with 2–5 cm of stomach above the diaphragm are commoner than large hernias [16] but Cameron lesions are usually found with large hernias.

Anemia in patients with large hernias was corrected by surgical repair in the majority of instances, but Cameron lesions were found in only about half of these individuals. [6] [7] One explanation is that endoscopists unfamiliar with their appearance can miss the lesions [10] [15] [17] However, in the original description of Cameron lesions [1] they were found in less than half the patients despite careful search, and no other causes of gastrointestinal bleeding. were seen. It is probable that these superficial lesions can heal and recur, with the bleeding stopping temporarily [1] [2] [18]

Diagnosis

Cameron lesions are usually found in older adults with anemia symptoms such as fatigue, shortness of breath, and appearing pale. Blood tests in iron deficiency show low hemoglobin, microcytic hypochromic red cells, and low iron-binding saturation and ferritin levels. The lesions are visualized by esophagogastroduodenoscopy. Sometimes the lesions are found when endoscopy is done for other hernia symptoms than anemia such as heartburn, regurgitation, swallowing difficulty, pain or distention. [9] When a person with iron deficiency anemia is found to have a large hernia and Cameron lesions on endoscopy, this usually explains the blood loss. A lower gastrointestinal bleeding site such as colon cancer may be excluded by colonscopy. and other tests as clinically indicated.

Treatment

Anemia associated with Cameron lesions usually responds to oral iron medication, which may be needed for years. [1] Gastric acid suppression may promote lesion healing [18] and a proton-pump inhibitor such as omeprazole is often prescribed. [10] [11] [14] Surgical hernia repair is sometimes needed [1] [7] for indications such as refractory anemia requiring repeated blood transfusions, or anemia combined with other hernia symptoms.

Related Research Articles

Peptic ulcer disease Ulcer of an area of the gastrointestinal tract

Peptic ulcer disease (PUD) is a break in the inner lining of the stomach, the first part of the small intestine, or sometimes the lower esophagus. An ulcer in the stomach is called a gastric ulcer, while one in the first part of the intestines is a duodenal ulcer. The most common symptoms of a duodenal ulcer are waking at night with upper abdominal pain and upper abdominal pain that improves with eating. With a gastric ulcer, the pain may worsen with eating. The pain is often described as a burning or dull ache. Other symptoms include belching, vomiting, weight loss, or poor appetite. About a third of older people have no symptoms. Complications may include bleeding, perforation, and blockage of the stomach. Bleeding occurs in as many as 15% of cases.

Anemia Medical condition

Anemia or anaemia is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, the symptoms are often vague, such as tiredness, weakness, shortness of breath, headaches, and a reduced ability to exercise. When anemia is acute, symptoms may include confusion, feeling like one is going to pass out, loss of consciousness, and increased thirst. Anemia must be significant before a person becomes noticeably pale. Additional symptoms may occur depending on the underlying cause. Preoperative anemia can increase the risk of needing a blood transfusion following surgery. Anemia can be temporary or long term and can range from mild to severe.

Hiatal hernia Type of hernia

A hiatal hernia or hiatus hernia is a type of hernia in which abdominal organs slip through the diaphragm into the middle compartment of the chest. This may result in gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) with symptoms such as a taste of acid in the back of the mouth or heartburn. Other symptoms may include trouble swallowing and chest pains. Complications may include iron deficiency anemia, volvulus, or bowel obstruction.

Upper gastrointestinal bleeding Medical condition

Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit or in altered form as black stool. Depending on the amount of the blood loss, symptoms may include shock.

Hematemesis is the vomiting of blood. It is always an important sign. It can be confused with hemoptysis or epistaxis (nosebleed), which are more common. The source is generally the upper gastrointestinal tract, typically above the suspensory muscle of duodenum. It may be caused by ulcers, tumors of the stomach or esophagus, varices, prolonged and vigorous retching, gastroenteritis, ingested blood, or certain drugs.

Coffee ground vomitus refers to a particular appearance of vomit. Within organic heme molecules of red blood cells is the element iron, which oxidizes following exposure to gastric acid. This reaction causes the vomitus to look like ground coffee. Coffee ground vomitus is a sign of possible upper gastrointestinal bleeding but studies show that it may not require urgent endoscopy.

Iron-deficiency anemia Medical condition

Iron-deficiency anemia is anemia caused by a lack of iron. Anemia is defined as a decrease in the number of red blood cells or the amount of hemoglobin in the blood. When onset is slow, symptoms are often vague such as feeling tired, weak, short of breath, or having decreased ability to exercise. Anemia that comes on quickly often has more severe symptoms, including confusion, feeling like one is going to pass out or increased thirst. Anemia is typically significant before a person becomes noticeably pale. Children with iron deficiency anemia may have problems with growth and development. There may be additional symptoms depending on the underlying cause.

Dieulafoys lesion Medical condition

Dieulafoy's lesion is a medical condition characterized by a large tortuous arteriole most commonly in the stomach wall (submucosal) that erodes and bleeds. It can present in any part of the gastrointestinal tract. It can cause gastric hemorrhage but is relatively uncommon. It is thought to cause less than 5% of all gastrointestinal bleeds in adults. It was named after French surgeon Paul Georges Dieulafoy, who described this condition in his paper "Exulceratio simplex: Leçons 1-3" in 1898. It is also called "caliber-persistent artery" or "aneurysm" of gastric vessels. However, unlike most other aneurysms, these are thought to be developmental malformations rather than degenerative changes.

Gastric bypass surgery Type of bariatric surgery

Gastric bypass surgery refers to a technique in which the stomach is divided into a small upper pouch and a much larger lower "remnant" pouch and then the small intestine is rearranged to connect to both. Surgeons have developed several different ways to reconnect the intestine, thus leading to several different gastric bypass procedures (GBP). Any GBP leads to a marked reduction in the functional volume of the stomach, accompanied by an altered physiological and physical response to food.

Gastrointestinal bleeding Medical condition

Gastrointestinal bleeding, also called gastrointestinal hemorrhage (GIB), is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool. Small amounts of bleeding over a long time may cause iron-deficiency anemia resulting in feeling tired or heart-related chest pain. Other symptoms may include abdominal pain, shortness of breath, pale skin, or passing out. Sometimes in those with small amounts of bleeding no symptoms may be present.

Gastritis Stomach disease that is an inflammation of the lining of the stomach

Gastritis is inflammation of the lining of the stomach. It may occur as a short episode or may be of a long duration. There may be no symptoms but, when symptoms are present, the most common is upper abdominal pain. Other possible symptoms include nausea and vomiting, bloating, loss of appetite and heartburn. Complications may include stomach bleeding, stomach ulcers, and stomach tumors. When due to autoimmune problems, low red blood cells due to not enough vitamin B12 may occur, a condition known as pernicious anemia.

Gastrointestinal disease Medical condition

Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the oesophagus, stomach, small intestine, large intestine and rectum, and the accessory organs of digestion, the liver, gallbladder, and pancreas.

Blood in stool Medical condition

Blood in stool looks different depending on how early it enters the digestive tract—and thus how much digestive action it has been exposed to—and how much there is. The term can refer either to melena, with a black appearance, typically originating from upper gastrointestinal bleeding; or to hematochezia, with a red color, typically originating from lower gastrointestinal bleeding. Evaluation of the blood found in stool depends on its characteristics, in terms of color, quantity and other features, which can point to its source, however, more serious conditions can present with a mixed picture, or with the form of bleeding that is found in another section of the tract. The term "blood in stool" is usually only used to describe visible blood, and not fecal occult blood, which is found only after physical examination and chemical laboratory testing.

Gastric antral vascular ectasia Medical condition

Gastric antral vascular ectasia (GAVE) is an uncommon cause of chronic gastrointestinal bleeding or iron deficiency anemia. The condition is associated with dilated small blood vessels in the pyloric antrum, which is a distal part of the stomach. The dilated vessels result in intestinal bleeding. It is also called watermelon stomach because streaky long red areas that are present in the stomach may resemble the markings on watermelon.

Gastric outlet obstruction Medical condition

Gastric outlet obstruction (GOO) is a medical condition where there is an obstruction at the level of the pylorus, which is the outlet of the stomach. Individuals with gastric outlet obstruction will often have recurrent vomiting of food that has accumulated in the stomach, but which cannot pass into the small intestine due to the obstruction. The stomach often dilates to accommodate food intake and secretions. Causes of gastric outlet obstruction include both benign causes, as well as malignant causes, such as gastric cancer.

Stool guaiac test Test for the presence for occult blood

The stool guaiac test or guaiac fecal occult blood test (gFOBT) is one of several methods that detects the presence of fecal occult blood. The test involves placing a fecal sample on guaiac paper and applying hydrogen peroxide which, in the presence of blood, yields a blue reaction product within seconds.

Gastric volvulus or volvulus of stomach is a twisting of all or part of the stomach by more than 180 degrees with obstruction of the flow of material through the stomach, variable loss of blood supply and possible tissue death. The twisting can occur around the long axis of the stomach: this is called organoaxial or around the axis perpendicular to this, called mesenteroaxial. Obstruction is more likely in organoaxial twisting than with mesenteroaxial while the latter is more associated with ischemia. About one third of the cases are associated with a hiatus hernia. Treatment is surgical.

Gastric erosion occurs when the mucous membrane lining the stomach becomes inflamed. Specifically, the term "erosion," in this context means damage that is limited to the mucosa. An erosion is different from an ulcer. An "ulcer" is an area of damage to the gastrointestinal wall that extends deeper through the wall than an erosion. See gastrointestinal wall.

Endoclip

An endoclip is a metallic mechanical device used in endoscopy in order to close two mucosal surfaces without the need for surgery and suturing. Its function is similar to a suture in gross surgical applications, as it is used to join together two disjointed surfaces, but, can be applied through the channel of an endoscope under direct visualization. Endoclips have found use in treating gastrointestinal bleeding, in preventing bleeding after therapeutic procedures such as polypectomy, and in closing gastrointestinal perforations. Many forms of endoclips exist of different shapes and sizes, including two and three prong devices, which can be administered using single use and reloadable systems, and may or may not open and close to facilitate placement.

A stress ulcer is a single or multiple mucosal defect which can become complicated by upper gastrointestinal bleeding or physiologic stress. Ordinary peptic ulcers are found commonly in the gastric antrum and the duodenum whereas stress ulcers are found commonly in fundic mucosa and can be located anywhere within the stomach and proximal duodenum.

References

  1. 1 2 3 4 5 6 7 Cameron AJ, Higgins JA. Linear gastric erosions. A lesion associated with large diaphragmatic hernia chronic blood loss anemia. Gastroenterology 1986;91:338-42. PMID   3487479
  2. 1 2 3 Holt JM, Mayet FGH, Warner GT, et al. Iron absorption and blood loss in patients with hiatus hernia. British Medical Journal 1968;3:22-25. PMC   1989480
  3. ↑ Kerlin P, Reiner R, Davies M, et al. Iron deficiency anemia-a prospective study. Australia and New Zealand Journal of Medicine 1979;9:402-407. PMID   315771
  4. 1 2 Windsor CWO, Collis JL. Anemia and hiatus hernia: experience in 450 patients. Thorax 1967;22:73-78. PMC   471591.
  5. ↑ Cameron AJ. Incidence of iron deficiency anemia in patients with large diaphragmatic hernia. Mayo Clinic Proceedings 1976;51:767-769. PMID   1086935
  6. 1 2 Carrott PW, Markar SR, Hong J, et al. Iron-deficiency anemia is a common presenting issue with giant paraesophageal hernia and resolves following repair. Journal of Gastrointestinal Surgery 2013;17:858-862 PMID   23515913.
  7. 1 2 3 Trastek VF, Allen MS, Deschamps C, et al. Diaphragmatic hernia and associated anemia: response to surgical treatment. Journal of Thoracic and Cardiovascular Surgery 1996;112:1340-1345. PMID   8911332
  8. ↑ Boutelier P, Ostovany J, deMestier P. Les complications hemorragigues des hernies hiatales. La Nouv Presse Med 1980;9:3071-3074. PMID   6969393
  9. 1 2 Weston AP. Hiatal hernia with Cameron ulcers and erosions. Gastrointestinal Endoscopy Clinics of North America 1996;6:671-679. PMID   8899401
  10. 1 2 3 Kimer N, Schmidt PN, Krag A. Cameron lesions: an often overlooked cause of iron deficiency anemia in patients with large hiatal hernias. BMJ case report; Published online Oct 28, 2010. doi : 10.1136/bcr.06.2010.3129. PMID   22791730
  11. 1 2 Ozyadin I, Dogan S, Aslaner A, et al. A rare cause of anemia due to upper gastrointestinal bleeding: Cameron lesion. American Journal of Experimental and Clinical Research 2014;1:16-17.
  12. ↑ Maganty K, Smith RL. Cameron lesions; unusual cause of gastrointestinal bleeding and anemia. Digestion 2008;77:214-217. PMID   18622137
  13. ↑ Lin CC, Chen TH, Ho WC, et al. Endoscopic treatment of a Cameron lesion presenting as life-threatening gastrointestinal hemorrhage. Journal of Clinical Gastroenterology 2001;33:423-424. PMID   11606864
  14. 1 2 3 Camus M, Jensen DM, Ohning GV, et al. Severe upper gastrointestinal hemorrhage from linear gastric ulcers in large hiatal hernias: A large prospective study of Cameron ulcers. Endoscopy 2013;45;397-400. PMID   23616128
  15. 1 2 Chun CL, Conti CA, Triadafilopoulos G. Cameron ulcers; you will find only what you seek. Digestive Diseases and Sciences 2011;56:3450-3452. PMID   21706202
  16. ↑ Cameron AJ. Barrett's esophagus: prevalence and size of hiatal hernia. American Journal of Gastroenterology 1999;94:2054-2059. PMID   10445527
  17. ↑ Morrissey JF. You see what you look for. Gastroenterology 1986;91:481-482. PMID   3487480
  18. 1 2 Moskovitz M, Fadden R, Min T, et al. Large hiatal hernias, anemia, and linear gastric erosion: studies of etiology and medical therapy. American Journal of Gastroenterology 1992;87:622-626. PMID   1595651

Original photos in figures 1,2,3 and 4 by AJCameron, published in Gastroenterology 1986; 91: 338–342, see ref#1. This is an Elsevier journal. A letter from the Elsevier permissions help desk affirms that authors retain right to use their article in full or in part to prepare other derivative works, and as this is a retained right, no written permission is necessary, but acknowledgement should be made.

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