Title : Endoscopic correlation between Cameron lesion characteristics, hiatal hernia anatomy, and gastroesophageal reflux disease: A single-center retrospective analysis
Abstract:
Background: Cameron lesions — linear erosions or ulcerations at the diaphragmatic pinch within a hiatal hernia (HH) — are an under-recognized cause of occult gastrointestinal bleeding and chronic iron-deficiency anemia. They are classically associated with large HH, but the endoscopic anatomical features that determine lesion number and size, and their relationship with reflux esophagitis and Barrett's esophagus, remain incompletely characterized.
Aim: To characterize the endoscopic anatomical correlates of Cameron lesions in patients with HH, and to explore their association with hernia size/type, reflux esophagitis severity, Barrett's esophagus, and clinical presentation.
Methods: We retrospectively analyzed 43 consecutive patients (65.1% female; mean age 60.3 ± 12.8 years, range 31–83) diagnosed endoscopically with HH and Cameron lesions. Hiatal hernias were graded using the Hill classification, size category (small/medium/large), reducibility (fixed/reducible/mixed), and maximal cranio-caudal height. For each patient, we recorded the number and maximal diameter of Cameron lesions, esophagitis severity (Los Angeles classification), Barrett's esophagus (Prague C&M criteria), bleeding stigmata (Forrest classification), H. pylori status, and presenting symptoms. Spearman correlation and Kruskal–Wallis tests were used to assess associations between hernia anatomy and Cameron lesion burden.
Results: Hill grade III–IV was present in 97.7% of patients, and HH was medium or large in 79.1% (mean maximal height 51.8 ± 24.6 mm; range 20–120 mm). Patients harbored a mean of 3.9 ± 1.9 Cameron lesions each (range 1–10; 166 lesions in total), with a mean maximal diameter of 20.1 ± 6.9 mm (range 5–40 mm). Neither the number nor the maximal size of Cameron lesions correlated with hernia height (rs = −0.02, p = 0.90 and rs = 0.15, p = 0.34, respectively), nor did they differ significantly across hernia-size categories (Kruskal–Wallis, p = 0.92 and p = 0.31) — indicating that, within this Cameron-lesion cohort, lesion burden is largely dissociated from gross hernia dimensions. Concurrent erosive esophagitis was present in 60.5% of patients and Barrett's esophagus (columnar-lined esophagus) in 14.0%. Forrest I–II bleeding stigmata were observed in 44.2% of examinations; anemia and overt upper gastrointestinal bleeding accounted for 20.9% and 9.3% of presentations, respectively. Malignant transformation of a Cameron lesion was observed in one case (2.3%). Laparoscopic Nissen fundoplication was the predominant treatment (69.8%).
Conclusion: Cameron lesions occurred across the full spectrum of hiatal hernia size and reducibility, and their number and diameter were statistically independent of hernia height in this cohort, arguing against a purely size-dependent mechanical model. The high prevalence of concurrent reflux esophagitis and Barrett's esophagus supports a combined mechanical–reflux pathogenesis. These findings support systematic, careful inspection of the hernia sac at upper endoscopy — including retroflexed views — regardless of hernia dimensions, particularly in patients presenting with unexplained iron-deficiency anemia.
Keywords: Cameron lesions; hiatal hernia; gastroesophageal reflux disease; Barrett's esophagus; upper gastrointestinal bleeding; endoscopy
