the three main causes of anaemia are blood loss , lack of red blood cell production , and high rates of red blood cell destruction .
blood loss is the most common cause of anaemia , especially iron - deficiency anaemia ( ida ) . between 2 and 5% of
adult men and postmenopausal women in the developed world have ida [ 1 , 2 ] . in premenopausal women ,
menstrual blood loss is the most common cause for ida , but , in postmenopausal women and men , the commonest cause is blood loss from the gastrointestinal ( gi ) tract [ 36 ] .
the most frequent causes of occult gi blood loss are nonsteroidal anti - inflammatory drugs , colonic cancer / polyp , gastric cancer , angiodysplasia , crohn 's disease , and ulcerative colitis .
therefore , an upper and lower endoscopy is an important and necessary examination in the assessment of anaemic patients .
apart from the more usual causes of ida , there are also less frequent and often overlooked causes of gi blood loss , such as paraoesophageal herniae ( ph ) .
the prevalence of ida in patients with large ph is between 6 and 37% [ 811 ] , a clinical correlation first established by segal in 1931 .
however , the exact cause of this association is not fully elucidated . in 1986 ,
cameron and higgins described the presence of linear gastric erosions at the waist of the hernia ( so called cameron lesions ) , which can cause chronic blood loss . although the association between cameron lesions and hiatal hernias is well described [ 14 , 15 ] , the pathophysiological mechanisms underlying these lesions remain unclear .
however , these lesions do not fully explain ida , as only 1/3 or less of anaemic patients with a large ph might have cameron lesions at endoscopy [ 9 , 18 ] .
although ida is a recognised complication of hiatus hernia , there are few published data regarding the incidence and outcome of severe , transfusion - dependent ida in patients with ph ( as opposed to mild anaemia not requiring treatment ) .
the aim of this study was to specifically identify such patients and to assess resolution of the anaemia after laparoscopic repair of the hiatal hernia .
between august 2006 and november 2010 , data were collected prospectively on all patients undergoing laparoscopic repair of ph .
patients were followed up routinely with clinical assessment and blood tests to assess the resolution of anaemia and other hernia - related symptoms .
patients with severe ida ( haemoglobin < 8  g / dl )   requiring red cell transfusion or iron infusion were retrospectively identified from the prospective database .
all procedures were completed laparoscopically with the patient in the modified lithotomy position and the surgeon standing between the patient 's legs .
the hernia sac was dissected away from its mediastinal attachments and the oesophagus dissected to ensure adequate intra - abdominal length .
after the crural pillars were approximated with 0 ethibond sutures ( ethicon , johnson & johnson , cincinnati , ohio , usa ) , timesh titanized polypropylene mesh ( biomed biologics , nuremberg , germany ) was fixed to the crural muscle with laparoscopic helical screws ( protack 5  mm ; covidien , mansfield , ma , usa ) .
seven patients ( 5.1% ; m  :  f 2  :  5 ; median age 62 years ( 5782 ) ) were identified as having a transfusion - dependent ( blood or iron ) anaemia at surgical presentation . amongst the group ,
the most common symptoms beside anaemia were chest pain ( n = 4 ) , shortness of breath ( n = 3 ) , regurgitation ( n = 3 ) , dysphagia ( n = 1 ) , and heartburn ( n = 1 ) .
the median time duration between symptom onset and date of surgery was 12.0 months ( range 3120 months ) .
appropriately , all patients had undergone preoperative diagnostic upper gi endoscopy , 6/7 had undergone diagnostic colonoscopy , and 3/7 had undergone capsule endoscopy .
however , as ph was not considered as an explanatory cause for severe , transfusion - dependent ida or gastric ulceration , several patients waited significant lengths of time prior to being considered for surgery ( in one case , 10 years ) . during these delays in surgical treatment ,
2/7 patients underwent unnecessary repeated endoscopic investigations after initial tests had yielded negative findings and a further patient underwent a second upper gi endoscopy to check for resolution of gastric ulceration ( cameron lesion ) before being referred for surgery .
( any follow - up endoscopy could have been performed at the time of surgery . ) in total , these 3 patients underwent the following :  patient 1 : 10 upper gi endoscopies , 10 colonoscopies , and 2 capsule endoscopies ,  patient 2 : 3 upper gi endoscopies and 3 colonoscopies  patient 3 : 2 upper gi endoscopies .
patient 1 : 10 upper gi endoscopies , 10 colonoscopies , and 2 capsule endoscopies , patient 2 : 3 upper gi endoscopies and 3 colonoscopies patient 3 : 2 upper gi endoscopies .  
cameron lesions were historically identified in only 2 patients , but in 1 of these individuals the erosions had healed and disappeared prior to surgery ( patient 3 ) .
apart from the ph identified endoscopically , no other mucosal abnormalities were identified within the gi tracts of these 7 patients to explain ida .
haematological investigations also revealed no other potential causes of bleeding . during preoperative investigation and management , patients received either red cell transfusions ( n = 5 ) and/or iron infusions ( n = 2 ) .
another one of the patients was due to have a red cell transfusion but this did not occur prior to the date of operation .
in those patients receiving blood , the total number of units of packed red cells transfused ranged from 2 to 36 ( patient 1 received bimonthly blood transfusions for 6 years prior to surgery ) .
all patients underwent laparoscopic mesh repair of ph with a fundoplication procedure ( 6 posterior 270 toupet , and 1 anterior 180 dor procedure due to an inability to mobilise the fundus sufficiently for a posterior wrap ) .
the median postoperative stay was 3.5 days ( 25 days ) . during a follow - up period of 1 year
paraoesophageal ( or rolling ) hiatal hernias may affect adults of any age and sex but are most common in elderly women .
symptoms are due to the mechanical effects of the hernia and are therefore often resistant to pharmacological treatment .
in contrast to the more common sliding hiatal hernia , a ph can lead to volvulus with pain and obstructive symptoms or , as our series demonstrates , they can be associated with ida , including severe , transfusion - dependent anaemia .
in fact , severe anaemia appears to have a prevalence of 5% in these patients .
such anaemia may occur even in the apparent absence of cameron lesions or obvious bleeding focal points at endoscopy . in our series , only 2 patients were ever noted to have gastric erosions .
however , it is worth noting that , in 1 of these patients , the cameron lesions resolved , suggesting either that occult bleeding is an intermittent phenomenon that is not always present at the time of endoscopy or , less likely , that bleeding lesions are missed at endoscopy
. nevertheless , other authors have found no correlation between cameron lesions and visible gi blood loss   or haemoglobin levels .
an alternative explanation for ida might be that large hiatus hernias interfere with the absorption and regulation of dietary iron .
it is obviously vital that all patients with ida of unknown cause require upper gi endoscopy and colonoscopy .
however , in our patient group , despite the severity of anaemia , patients experienced symptoms for a median duration of 1 year before being referred to surgical services for a hiatal repair . during this preoperative assessment stage ,
3/7 patients underwent repeated endoscopic investigations and transfusions and were therefore unnecessarily exposed to the risk of procedure - related complications .
repeated upper gi endoscopy is appropriate in those requiring endoscopic treatment for acute life - threatening haemorrhage from upper gi ulceration but not in those with chronic ida .
it is therefore vitally important that physicians who assess patients with ida are cognisant of the correlation with hiatus hernia , particularly in the absence of erosive pathology at endoscopy .
any failure to appreciate this association might represent a lack of awareness on the part of physicians and surgeons managing ida . for example , a review of 7 core european and australasian surgical textbooks reveals that only 3 textbooks make reference to hiatus hernias being a cause of bleeding or anaemia , and , in these books , bleeding is chiefly attributed to reflux oesophagitis [ 2026 ] .
cameron lesions are described in only one of these textbooks , whereas ph as a cause of cryptogenic anaemia is not discussed in any of them .
gastrooesophageal reflux disease ( gord ) and oesophagitis do frequently coexist with hiatal hernias , and therefore oesophagitis may well be the cause of anaemia in some patients .
however , ph ( with or without cameron lesions ) should still be considered as an aetiological factor in severe ida . in our series ,
laparoscopic ph repair cured all patients of severe anaemia during a median follow - up period of 12 months .
hayden and jamieson also included 3 patients with transfusion - dependent anaemia in their series of 11 patients with ph and ida .
they also demonstrated resolution of patient anaemia during a median follow - up of 25 months .
therefore , it would seem appropriate to offer surgical intervention to young , medically fit patients with ph and severe ida with no other cause found on endoscopic investigation
. such an approach would also prevent the foregut and mechanical complications of ph , symptoms for which some authors would recommend routine surgical repair in any case .
this recommendation contrasts with those of panzuto et al . , who demonstrated in a randomised control trial that proton pump inhibitor ( ppi ) monotherapy was as effective as surgery with ppi at resolving ida in association with large hiatal hernia .
however , this study did not involve pure cohorts of patients with severe , transfusion dependent anaemia but also included individuals with mild anaemia .
many patients with ph are elderly and frail and thus a nonoperative approach might be appropriate in this group .
elderly patient age alone remains only a relative contraindication to surgery , however , as we have shown previously that laparoscopic repair is associated with acceptable rates of morbidity and a significant improvement in quality of life in such individuals .
in summary , we have identified a small but significant number of patients with severe ida in association with ph , often in the absence of endoscopically identifiable cameron lesions .
early recognition of the fact that ph may be an aetiological factor in severe ida will mitigate the likelihood of prolonged transfusion dependency and fruitless , repeated gi tract investigations as laparoscopic repair of ph resolves ida .
 
 introduction . 
 a paraoesophageal hernia ( ph ) may be one reason for iron - deficiency anaemia ( ida ) but is often overlooked as a cause . 
 we aimed to assess the incidence and resolution of transfusion - dependent ida in patients presenting for hiatal hernia surgery . 
 methods . 
 we analysed a prospective database of patients undergoing laparoscopic hiatal repair in order to identify patients with severe ida requiring red cell / iron transfusion . 
 results . of 138 patients with ph managed over a 4-year period , 7 patients ( 5.1% ; m  :  f 2  :  5 ; median age 62 yrs ( range 5782 ) ) with ida requiring red cell / iron transfusion were identified . 
 preoperatively , 3/7 patients underwent repetitive and unnecessary diagnostic endoscopic investigations prior to surgery . 
 only 2/7 ever demonstrated gastric mucosal erosions ( cameron ulcers ) . 
 all patients were cured from anaemia postoperatively . 
 discussion . 
 ph is an important differential diagnosis in patients with ida , even those with marked anaemia and no endoscopically identifiable mucosal lesions . 
 early recognition can avoid unnecessary additional diagnostic endoscopies . 
 laparoscopic repair is associated with low morbidity and results in resolution of anaemia . 
1. Introduction
2. Materials and Methods
3. Results
4. Discussion
5. Conclusion