A hiatal hernia can cause anemia, a condition where the body lacks sufficient red blood cells to transport oxygen. This occurs when a portion of the stomach pushes up through the diaphragm’s opening (the hiatus) into the chest cavity, leading to chronic internal bleeding. The resulting anemia is almost always Iron-Deficiency Anemia, which develops over an extended period.
Understanding Hiatal Hernias and Anemia
A hiatal hernia is an anatomical defect where the upper part of the stomach pushes into the chest through the diaphragm. There are two main types: the sliding (or axial) hernia, where the junction between the esophagus and stomach slides up, and the paraesophageal hernia, where a part of the stomach rolls up next to the esophagus. While sliding hernias are most common, larger hernias, including large sliding and paraesophageal types, are typically associated with chronic blood loss.
Anemia means the blood lacks enough healthy red blood cells or hemoglobin, the protein responsible for carrying oxygen. Hemoglobin production relies heavily on iron. When a hiatal hernia leads to continuous, low-level internal bleeding, the body loses iron faster than it can be absorbed from the diet. This chronic iron depletion results in Iron-Deficiency Anemia, characterized by small, pale red blood cells.
The Direct Mechanism: How Hernias Cause Chronic Blood Loss
The connection between a hiatal hernia and anemia is rooted in mechanical trauma that occurs within the chest cavity. As the herniated part of the stomach moves back and forth with breathing and swallowing, it is subjected to a pinching or rubbing action by the muscular diaphragm. This repetitive friction causes superficial damage to the stomach lining, leading to slow, persistent blood loss.
The most specific manifestation of this trauma is the formation of lesions known as Cameron lesions, which are linear erosions or ulcers found on the mucosal folds of the stomach within the hernia sac. These lesions develop precisely where the stomach tissue rubs against the diaphragm’s edge.
Cameron lesions are thought to result from a combination of mechanical injury and localized ischemia, or reduced blood flow, caused by the constant constriction. The bleeding from these lesions is typically occult, meaning it is hidden and not visible in stool or vomit. This makes the resulting anemia slow to develop and difficult to diagnose initially.
Although Cameron lesions are the most common cause, they are only found in about a third of patients with hernia-related Iron-Deficiency Anemia. This suggests that other small mucosal erosions or diffuse irritation from the constant mechanical stress can also contribute to the chronic iron-losing blood loss, even without visible ulcers. The size of the hernia is often correlated with the risk, as larger hernias are more prone to this mechanical irritation.
Diagnosis and Treatment Strategies
Diagnosis often begins with a complete blood count (CBC) to confirm anemia and a check of ferritin levels to measure the body’s iron stores. Once Iron-Deficiency Anemia is confirmed, a comprehensive search for the source of chronic blood loss is necessary, typically involving an upper endoscopy and sometimes a colonoscopy to rule out other gastrointestinal issues. During the upper endoscopy, a doctor visually inspects the stomach and esophagus, specifically looking for Cameron lesions near the diaphragmatic impression.
Treatment involves managing the anemia and addressing the anatomical cause. Anemia management involves prescribing oral iron supplements to replenish depleted iron stores, though blood transfusions may be necessary in severe cases. Medical treatment for the hiatal hernia usually includes proton pump inhibitors (PPIs) to reduce stomach acid, which helps existing erosions heal and prevents further irritation of the traumatized stomach lining.
If medical therapy fails to resolve the anemia or if the patient experiences severe symptoms, surgical repair of the hiatal hernia (hernioplasty) may be considered. The goal of surgery is to pull the stomach back into the abdomen and tighten the opening in the diaphragm, thus eliminating the mechanical friction that causes the bleeding. Long-term PPI therapy may be as effective as surgery in preventing the recurrence of anemia.