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Critical anemia • light-headedness • bilateral leg swelling • Dx?
THE CASE
A 40-year-old man was referred to the emergency department (ED) with critical anemia after routine blood work at an outside clinic showed a hemoglobin level of 3.5 g/dL. On presentation, he reported symptoms of fatigue, shortness of breath, bilateral leg swelling, dizziness (characterized as light-headedness), and frequent heartburn. He said that the symptoms began 5 weeks earlier, after he was exposed to a relative with hand, foot, and mouth disease.
Additionally, the patient reported an intentional 14-lb weight loss over the 6 months prior to presentation. He denied fever, rash, chest pain, loss of consciousness, headache, abdominal pain, hematemesis, melena, and hematochezia. His medical history was significant for peptic ulcer disease (diagnosed and treated at age 8). He did not recall the specifics, and he denied any related chronic symptoms or complications. His family history (paternal) was significant for colon cancer.
The physical exam revealed conjunctival pallor, skin pallor, jaundice, +1 bilateral lower extremity edema, tachycardia, and tachypnea. Stool Hemoccult was negative. On repeat complete blood count (performed in the ED), hemoglobin was found to be 3.1 g/dL with a mean corpuscular volume of 47 fL.
THE DIAGNOSIS
The patient was admitted to the family medicine service and received 4 units of packed red blood cells, which increased his hemoglobin to the target goal of >7 g/dL. A colonoscopy and an esophagogastroduodenoscopy (EGD) were performed (FIGURE 1A-1C), with results suggestive of diverticulosis, probable Barrett’s mucosa, esophageal ulcer, huge hiatal hernia (at least one-half of the stomach was in the chest), and Cameron ulcers. Esophageal biopsies showed cardiac mucosa with chronic inflammation. Esophageal ulcer biopsies revealed Barrett’s esophagus without dysplasia. Duodenal biopsies displayed normal mucosa.
DISCUSSION
Although rare, Cameron ulcers must be considered in the differential diagnosis of patients with chronic anemia of unknown origin. The potential for these lesions to result in chronic blood loss, which could over time manifest as severe anemia or hypovolemic shock, makes proper diagnosis and prompt treatment especially important.4,5
In our patient’s case, his severe anemia was likely the result of a combination of the esophageal and Cameron ulcers evidenced on EGD, rather than any single ulcer. In our review of the literature, we found no reports of any patients with anemia and Cameron ulcers who presented with hemoglobin levels as low as our patient had.
Treat with a PPI and iron supplementation
Multiple EGDs may be needed to properly diagnose Cameron ulcers, as they can be difficult to identify. Once a patient receives the diagnosis, he or she will typically be put on a daily proton pump inhibitor (PPI) regimen, such as omeprazole 20 mg bid. However, since many patients with Cameron ulcers also have acid-related problems (as was true in this case), a multifactorial acid suppression approach may be warranted.1 This may include recommending lifestyle modifications (eg, eating small meals, avoiding foods that provoke symptoms, or losing weight) and prescribing medications in addition to a PPI, such as an H2 blocker (eg, 300 mg qid, before meals and at bedtime).
In addition, iron sulfate (325 mg/d, in this case) and blood transfusions may be required to treat the anemia. In refractory cases, endoscopic or surgical interventions, such as hemoclipping, Nissen fundoplication, or laparoscopic gastropexy, may need to be performed.2
Our patient was given a prescription for ferrous sulfate 325 mg/d and omeprazole 20 mg bid. His symptoms improved with treatment, and he was discharged on Day 5; his hemoglobin remained >7 g/dL.
THE TAKEAWAY
The association between chronic iron deficiency anemia and Cameron ulcers has been established but is commonly overlooked in patients presenting with unexplained anemia or an undiagnosed hiatal hernia. This is likely due to their rarity as a cause of anemia, in general.
Furthermore, the lesions can be missed on EGD; multiple EGDs may be needed to make the diagnosis. Once diagnosed, Cameron ulcers typically respond well to twice daily PPI treatment. Patients with refractory, recurrent, or severe lesions, or large, symptomatic hiatal hernias should be referred for surgical assessment.
CORRESPONDENCE
Megan Yee, 801 Broadward Avenue NW, Grand Rapids, MI 49504; [email protected].
1. Maganty K, Smith RL. Cameron lesions: unusual cause of gastrointestinal bleeding and anemia. Digestion. 2008;77:214-217.
2. Camus M, Jensen DM, Ohning GV, et al. Severe upper gastrointestinal hemorrhage from linear gastric ulcers in large hiatal hernias: a large prospective case series of Cameron ulcers. Endoscopy. 2013;45:397-400.
3. Kimer N, Schmidt PN, Krag, A. Cameron lesions: an often overlooked cause of iron deficiency anaemia in patients with large hiatal hernias. BMJ Case Rep. 2010;2010.
4. Kapadia S, Jagroop S, Kumar, A. Cameron ulcers: an atypical source for a massive upper gastrointestinal bleed. World J Gastroenterol. 2012;18:4959-4961.
5. Gupta P, Suryadevara M, Das A, et al. Cameron ulcer causing severe anemia in a patient with diaphragmatic hernia. Am J Case Rep. 2015;16:733-736.
THE CASE
A 40-year-old man was referred to the emergency department (ED) with critical anemia after routine blood work at an outside clinic showed a hemoglobin level of 3.5 g/dL. On presentation, he reported symptoms of fatigue, shortness of breath, bilateral leg swelling, dizziness (characterized as light-headedness), and frequent heartburn. He said that the symptoms began 5 weeks earlier, after he was exposed to a relative with hand, foot, and mouth disease.
Additionally, the patient reported an intentional 14-lb weight loss over the 6 months prior to presentation. He denied fever, rash, chest pain, loss of consciousness, headache, abdominal pain, hematemesis, melena, and hematochezia. His medical history was significant for peptic ulcer disease (diagnosed and treated at age 8). He did not recall the specifics, and he denied any related chronic symptoms or complications. His family history (paternal) was significant for colon cancer.
The physical exam revealed conjunctival pallor, skin pallor, jaundice, +1 bilateral lower extremity edema, tachycardia, and tachypnea. Stool Hemoccult was negative. On repeat complete blood count (performed in the ED), hemoglobin was found to be 3.1 g/dL with a mean corpuscular volume of 47 fL.
THE DIAGNOSIS
The patient was admitted to the family medicine service and received 4 units of packed red blood cells, which increased his hemoglobin to the target goal of >7 g/dL. A colonoscopy and an esophagogastroduodenoscopy (EGD) were performed (FIGURE 1A-1C), with results suggestive of diverticulosis, probable Barrett’s mucosa, esophageal ulcer, huge hiatal hernia (at least one-half of the stomach was in the chest), and Cameron ulcers. Esophageal biopsies showed cardiac mucosa with chronic inflammation. Esophageal ulcer biopsies revealed Barrett’s esophagus without dysplasia. Duodenal biopsies displayed normal mucosa.
DISCUSSION
Although rare, Cameron ulcers must be considered in the differential diagnosis of patients with chronic anemia of unknown origin. The potential for these lesions to result in chronic blood loss, which could over time manifest as severe anemia or hypovolemic shock, makes proper diagnosis and prompt treatment especially important.4,5
In our patient’s case, his severe anemia was likely the result of a combination of the esophageal and Cameron ulcers evidenced on EGD, rather than any single ulcer. In our review of the literature, we found no reports of any patients with anemia and Cameron ulcers who presented with hemoglobin levels as low as our patient had.
Treat with a PPI and iron supplementation
Multiple EGDs may be needed to properly diagnose Cameron ulcers, as they can be difficult to identify. Once a patient receives the diagnosis, he or she will typically be put on a daily proton pump inhibitor (PPI) regimen, such as omeprazole 20 mg bid. However, since many patients with Cameron ulcers also have acid-related problems (as was true in this case), a multifactorial acid suppression approach may be warranted.1 This may include recommending lifestyle modifications (eg, eating small meals, avoiding foods that provoke symptoms, or losing weight) and prescribing medications in addition to a PPI, such as an H2 blocker (eg, 300 mg qid, before meals and at bedtime).
In addition, iron sulfate (325 mg/d, in this case) and blood transfusions may be required to treat the anemia. In refractory cases, endoscopic or surgical interventions, such as hemoclipping, Nissen fundoplication, or laparoscopic gastropexy, may need to be performed.2
Our patient was given a prescription for ferrous sulfate 325 mg/d and omeprazole 20 mg bid. His symptoms improved with treatment, and he was discharged on Day 5; his hemoglobin remained >7 g/dL.
THE TAKEAWAY
The association between chronic iron deficiency anemia and Cameron ulcers has been established but is commonly overlooked in patients presenting with unexplained anemia or an undiagnosed hiatal hernia. This is likely due to their rarity as a cause of anemia, in general.
Furthermore, the lesions can be missed on EGD; multiple EGDs may be needed to make the diagnosis. Once diagnosed, Cameron ulcers typically respond well to twice daily PPI treatment. Patients with refractory, recurrent, or severe lesions, or large, symptomatic hiatal hernias should be referred for surgical assessment.
CORRESPONDENCE
Megan Yee, 801 Broadward Avenue NW, Grand Rapids, MI 49504; [email protected].
THE CASE
A 40-year-old man was referred to the emergency department (ED) with critical anemia after routine blood work at an outside clinic showed a hemoglobin level of 3.5 g/dL. On presentation, he reported symptoms of fatigue, shortness of breath, bilateral leg swelling, dizziness (characterized as light-headedness), and frequent heartburn. He said that the symptoms began 5 weeks earlier, after he was exposed to a relative with hand, foot, and mouth disease.
Additionally, the patient reported an intentional 14-lb weight loss over the 6 months prior to presentation. He denied fever, rash, chest pain, loss of consciousness, headache, abdominal pain, hematemesis, melena, and hematochezia. His medical history was significant for peptic ulcer disease (diagnosed and treated at age 8). He did not recall the specifics, and he denied any related chronic symptoms or complications. His family history (paternal) was significant for colon cancer.
The physical exam revealed conjunctival pallor, skin pallor, jaundice, +1 bilateral lower extremity edema, tachycardia, and tachypnea. Stool Hemoccult was negative. On repeat complete blood count (performed in the ED), hemoglobin was found to be 3.1 g/dL with a mean corpuscular volume of 47 fL.
THE DIAGNOSIS
The patient was admitted to the family medicine service and received 4 units of packed red blood cells, which increased his hemoglobin to the target goal of >7 g/dL. A colonoscopy and an esophagogastroduodenoscopy (EGD) were performed (FIGURE 1A-1C), with results suggestive of diverticulosis, probable Barrett’s mucosa, esophageal ulcer, huge hiatal hernia (at least one-half of the stomach was in the chest), and Cameron ulcers. Esophageal biopsies showed cardiac mucosa with chronic inflammation. Esophageal ulcer biopsies revealed Barrett’s esophagus without dysplasia. Duodenal biopsies displayed normal mucosa.
DISCUSSION
Although rare, Cameron ulcers must be considered in the differential diagnosis of patients with chronic anemia of unknown origin. The potential for these lesions to result in chronic blood loss, which could over time manifest as severe anemia or hypovolemic shock, makes proper diagnosis and prompt treatment especially important.4,5
In our patient’s case, his severe anemia was likely the result of a combination of the esophageal and Cameron ulcers evidenced on EGD, rather than any single ulcer. In our review of the literature, we found no reports of any patients with anemia and Cameron ulcers who presented with hemoglobin levels as low as our patient had.
Treat with a PPI and iron supplementation
Multiple EGDs may be needed to properly diagnose Cameron ulcers, as they can be difficult to identify. Once a patient receives the diagnosis, he or she will typically be put on a daily proton pump inhibitor (PPI) regimen, such as omeprazole 20 mg bid. However, since many patients with Cameron ulcers also have acid-related problems (as was true in this case), a multifactorial acid suppression approach may be warranted.1 This may include recommending lifestyle modifications (eg, eating small meals, avoiding foods that provoke symptoms, or losing weight) and prescribing medications in addition to a PPI, such as an H2 blocker (eg, 300 mg qid, before meals and at bedtime).
In addition, iron sulfate (325 mg/d, in this case) and blood transfusions may be required to treat the anemia. In refractory cases, endoscopic or surgical interventions, such as hemoclipping, Nissen fundoplication, or laparoscopic gastropexy, may need to be performed.2
Our patient was given a prescription for ferrous sulfate 325 mg/d and omeprazole 20 mg bid. His symptoms improved with treatment, and he was discharged on Day 5; his hemoglobin remained >7 g/dL.
THE TAKEAWAY
The association between chronic iron deficiency anemia and Cameron ulcers has been established but is commonly overlooked in patients presenting with unexplained anemia or an undiagnosed hiatal hernia. This is likely due to their rarity as a cause of anemia, in general.
Furthermore, the lesions can be missed on EGD; multiple EGDs may be needed to make the diagnosis. Once diagnosed, Cameron ulcers typically respond well to twice daily PPI treatment. Patients with refractory, recurrent, or severe lesions, or large, symptomatic hiatal hernias should be referred for surgical assessment.
CORRESPONDENCE
Megan Yee, 801 Broadward Avenue NW, Grand Rapids, MI 49504; [email protected].
1. Maganty K, Smith RL. Cameron lesions: unusual cause of gastrointestinal bleeding and anemia. Digestion. 2008;77:214-217.
2. Camus M, Jensen DM, Ohning GV, et al. Severe upper gastrointestinal hemorrhage from linear gastric ulcers in large hiatal hernias: a large prospective case series of Cameron ulcers. Endoscopy. 2013;45:397-400.
3. Kimer N, Schmidt PN, Krag, A. Cameron lesions: an often overlooked cause of iron deficiency anaemia in patients with large hiatal hernias. BMJ Case Rep. 2010;2010.
4. Kapadia S, Jagroop S, Kumar, A. Cameron ulcers: an atypical source for a massive upper gastrointestinal bleed. World J Gastroenterol. 2012;18:4959-4961.
5. Gupta P, Suryadevara M, Das A, et al. Cameron ulcer causing severe anemia in a patient with diaphragmatic hernia. Am J Case Rep. 2015;16:733-736.
1. Maganty K, Smith RL. Cameron lesions: unusual cause of gastrointestinal bleeding and anemia. Digestion. 2008;77:214-217.
2. Camus M, Jensen DM, Ohning GV, et al. Severe upper gastrointestinal hemorrhage from linear gastric ulcers in large hiatal hernias: a large prospective case series of Cameron ulcers. Endoscopy. 2013;45:397-400.
3. Kimer N, Schmidt PN, Krag, A. Cameron lesions: an often overlooked cause of iron deficiency anaemia in patients with large hiatal hernias. BMJ Case Rep. 2010;2010.
4. Kapadia S, Jagroop S, Kumar, A. Cameron ulcers: an atypical source for a massive upper gastrointestinal bleed. World J Gastroenterol. 2012;18:4959-4961.
5. Gupta P, Suryadevara M, Das A, et al. Cameron ulcer causing severe anemia in a patient with diaphragmatic hernia. Am J Case Rep. 2015;16:733-736.
