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CHRONIC ANEMIA AND GASTROINTESTINAL BLEEDING IN PATIENTS UNDERGOING PRIMARY HIATAL HERNIA REPAIR
Andrés R. Latorre-Rodríguez
*1,2, Hailey Simmonds
3, Raj Shah
4, Sumeet K. Mittal
1,31Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ; 2Universidad del Rosario. Escuela de Medicina y Ciencias de la Salud, Bogotá D.C., Colombia; 3Creighton University School of Medicine, Phoenix, AZ; 4University of Arizona School of Medicine, Phoenix, AZ
Background: Surgical primary hiatal hernia (HH) repair is performed for various clinical presentations, including gastroesophageal reflux (GERD) and obstructive symptoms. However, HHs are also associated with chronic anemia and/or upper gastrointestinal (GI) bleeding, which is frequently overlooked. We aimed to determine the prevalence of chronic anemia/bleeding among patients undergoing primary HH repair, and explore its correlation with HH size.
Methods: After IRB approval, we conducted a retrospective observational study using a maintained database of patients who underwent minimally invasive HH repair by a single foregut surgeon between September 2016 and March 2024. Inclusion criteria were:
i) hemoglobin (Hb) values in the anemia range according to WHO definitions (<13.5 g/dL in men; <12.0 g/dL in women),
ii) endoscopic evidence of Cameron erosions,
iii) diagnosis of chronic anemia, or
iv) a history of anemia therapy as per medical records. Exclusion criteria included history of bariatric surgery, redo procedures, active hematological disorders, or other identifiable blood loss sources. HH size was defined by stomach proportion in the thorax: small-HH (<25%), moderate-HH (25-49%), large-HH (50-74%), and ITS (?75%). Descriptive and inferential statistics were applied as appropriate.
Results: Of the 448 patients who underwent primary HH repair, 142 (31.7%) had preoperative anemia or bleeding without other identifiable sources of blood loss (110 women [77.5%]; median age: 69 years [IQR 60–76]; median BMI: 29.5 kg/m
2 [IQR 25.7–32.9]). Anemia/bleeding prevalence increased with HH size (small-HH: 10.6%, moderate-HH: 30%, large-HH: 60.8%, ITS: 47.3%, p<0.05) (
Figure 1). Among these, 85 of 142 (60.7%) had anemia per WHO definitions (female patients: median Hb 9.8 g/dL [IQR 7.3–10.8]; male patients: median Hb 11.2 g/dL [IQR 10.7–12.4]). Additionally, 29 (20.4%) had documented chronic anemia or upper GI bleeding, and 65 (45.8%) exhibited Cameron erosions on preoperative esophagogastroduodenoscopy. Moreover, 84 (59.2%) received therapies for anemia, including packed red blood cell transfusions (n=30), iron infusions (n=13), or oral iron (n=47).
Conclusion: HH appears to be an under-recognized but important cause of anemia and/or GI bleeding, and the progressive nature of this disease (i.e., increasing size over time) is associated with an increasing incidence of this particular presentation. Early referral for surgical management in patients with HH and anemia should be considered, as medical therapy may not address the underlying cause.
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