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 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.
A Cameron ulcer is a gastric lesion that is typically linear and found in hiatal hernias. These ulcers are often localized to areas where the herniated stomach is narrowed by the surrounding diaphragm, but they can extend onto the lesser curvature.1 They are found in approximately 5% of patients with hiatal hernias (and an even higher percentage when the hernias are >5 cm1,2).3 Because physical agitation of the ulcer-containing hernia occurs when the patient breathes, these ulcers can be the source of otherwise unexplained chronic iron-deficiency anemia in this patient population.3 While some patients present with typical symptoms of anemia or gastrointestinal bleeding, such as fatigue, pallor, hematemesis, and melena, others have a much subtler clinical picture or may be asymptomatic altogether.4
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.