A 78-year-old man with a history of coronary artery disease and type 2 diabetes mellitus presented to the emergency department with chest pressure and epigastric pain of 3 hours’ duration. He did not have shortness of breath. Associated symptoms included nausea, diaphoresis, and pain in the left side of his neck. Electrocardiogram findings and troponin level were unremarkable. A chest radiograph showed a large hiatal hernia (image A), and a computed tomographic image of the chest (image B) revealed a type II paraesophageal hernia, later determined to involve strangulation of the gastric fundus. The patient underwent hernia reduction, partial gastrectomy, and repair of the hiatus with synthetic mesh. His hospital stay was prolonged and complicated. 

Hiatal hernias are categorized into 4 subtypes: sliding hernia (type I) is the most common type of hiatal hernia (95% of cases) and is rarely associated with severe complications. Paraesophageal hernias, however, involve herniation of the gastric fundus (type II and III) or, occasionally, other abdominal organs (type IV) and have at least an 18% lifetime risk of requiring emergent surgical correction.^1-3 The estimated mortality rate of acutely symptomatic paraesophageal hiatal hernias (types II through IV) is 16.4% without and 3.2% with an emergent surgical procedure.^{2, 3} Complicated paraesophageal hernia should be considered in patients with chest or upper abdominal pain and a large retrocardiac air-fluid level visible on chest radiograph.¹ (doi:10.7556/jaoa.2015.055)