Abstract
Introduction
Upper gastrointestinal bleeding is common in the adult population. Peptic ulcer disease is a common cause of gastrointestinal bleeding and is usually related to Helicobacter pylori (H. pylori) infection or nonsteroidal anti-inflammatory drugs. Patients with a large hiatal hernia are at risk for a Cameron ulcer, which has a different physiology and treatment options.
Case Report
A 64-year-old woman presented with multiple episodes of melena followed by a syncopal episode and coffee-ground emesis. Her past medical history was notable for GERD and a hiatal hernia diagnosed on esophagogastroduodenoscopy (EGD) in 2008; she denied any NSAID use. Her GERD had been well-controlled on esomeprazole, but she stopped taking this medication two months before her presentation due to a concern over long-term side effects. On presentation, her blood hemoglobin level was 9.8 g/dL, decreased from a baseline of 14 g/dL. She underwent EGD which confirmed a large hiatal hernia and showed a 1 cm ulcer with a visible vessel located along the diaphragmatic impression, consistent with a Cameron ulcer. The ulcer was treated with epinephrine injection and bipolar cautery. Gastric biopsies were obtained, which later retuned negative for H. pylori. A proton pump inhibitor was restarted and she recovered uneventfully. Repeat upper endoscopy two months later showed complete resolution of her Cameron's ulcer. After a discussion of therapeutic options, she was referred for fundoplication and surgical repair of her hiatal hernia.
Discussion
Cameron ulcers are a mechanical phenomenon, related to extrinsic compression of the diaphragm on the stomach in patients with large hiatal hernias. These lesions should be suspected during upper endoscopy in patients with large hiatal hernias as Cameron ulcers may be overlooked due to their location along the diaphragmatic impression. Although our patient's ulcer resolved after she was restarted on a proton pump inhibitor, surgical repair of the hiatal hernia (often performed in combination with a fundoplication) is a consideration in patients who fail to respond to standard therapy.
Conflict of Interest
The authors report no conflict of interest.