The patient was a 74-year-old female who complained of anemia for more than 30 years, intermittently treated with oral iron supplements, but not regularly, and the improvement of anemia was unknown. 2 years ago, she had a history of blood transfusion. This time, the patient came to the clinic with “weakness and poor appetite for 2 weeks”. She reported that she had weakness and poor appetite for 2 weeks without any obvious cause, manifesting as: lack of desire to eat, tastelessness, half of the meal quantity, accompanied by dizziness, palpitation, shortness of breath, denied nausea, bloating, no vomiting, abdominal pain, belching, erratic discomfort, no acid reflux, heartburn, denied blood in stool, constipation, no fever, jaundice, no attention and no treatment. He was first admitted to the internal medicine department for treatment, and at the same time, relevant laboratory and auxiliary examinations were improved, and he was transferred to surgery for further treatment after a clear diagnosis was made. Let’s look at the laboratory and examination after admission: a. Blood routine and changes after blood transfusion (400ml). b. The picture below shows the barium fluoroscopy of the digestive tract. c, abdominal CT and volumetric measurements. The patient underwent laparoscopic giant esophageal hiatal hernia patch repair (to protect the hepatobiliary branch of the vagus nerve) + gastric torsion repositioning + fundoplication under general anesthesia after complete preoperative laboratory tests and examinations to exclude malignant diseases, and adequate preoperative preparation, and the operation went smoothly with good postoperative recovery and gradual hematocrit recovery. From the above, we know that this is a neglected case of anemia secondary to esophageal hiatal hernia, so what is esophageal hiatal hernia? What are the causes and characteristics of secondary anemia? How to treat it? a. Hiatus hernia (HH) is an anatomical abnormality formed when any abdominal tissue or organ other than the esophagus is displaced upward into the thoracic cavity through an enlarged esophageal hiatus. The stomach, which is connected to the esophagus, is the main organ that herniates into the thoracic cavity. The incidence of HH has been reported to be 0.8% to 2.9%, with 15% to 45% of HH secondary to anemia. Currently, HH is usually classified into 4 types. (1) Type I HH is sliding HH, in which the gastroesophageal junction is displaced above the diaphragm. The stomach remains in a longitudinal posture and the fundus is below the gastroesophageal junction. Type II HH is a simple paraesophageal hernia (PEH) in which the gastroesophageal junction remains in its normal anatomic position, but a portion of the gastric fundus enters the thoracic cavity through the esophageal hiatus. Type III HH is a combination of type I and type II, in which both the gastroesophageal junction and the fundus enter the thoracic cavity through the esophageal foramen. The fundus is located above the gastroesophageal junction. Type IV HH is characterized by the presence of tissues and organs other than the stomach in the hernia sac, such as the greater omentum, colon, small intestine, spleen, and pancreas. More than 95% of these HHs are type I. b. Anemia secondary to esophageal hiatal hernia is not uncommon clinically, but the lack of specificity in clinical presentation can easily lead to misdiagnosis and underdiagnosis. 1986 Cameron et al. first described linear erosions and ulcers at the level of the gastric diaphragm in anemic patients by endoscopy and concluded that these linear lesions were associated with anemia secondary to HH. Gastrointestinal bleeding due to Cameron’s lesion can be overt or occult Most patients eventually develop iron deficiency anemia (IDA). Patients with HH secondary anemia have the following characteristics: 1. Patients are older and mainly have GI symptoms, while a small number of patients will start with chest tightness and chest pain; 2. Chronic occult GI blood loss is the main cause, while a small number of patients will have acute GI bleeding; 3. Cameron lesions are found in less than 50% of patients with HH secondary anemia, and clinicians should raise awareness of Cameron lesions. It needs to be differentiated from GI tumors, coronary artery disease, and other diseases. This patient is a composite of the above 3 points. c. For the treatment of HH, we currently use individualized treatment, which can be preceded by pharmacological treatment. If the anemia cannot be corrected by drugs, elective esophageal hiatal hernia repair + fundoplication (laparoscopic surgery is recommended) can be performed.