A 79-year-old woman presented to the emergency department with abrupt onset of dark-colored emesis. Her medical history included hypertension and cecal carcinoma. Physical examination and laboratory findings were normal. A radiographic image of the chest from an anterior/posterior view showed a retrocardiac air bubble (image, arrows), indicating a massive incarcerated paraesophageal hiatal hernia. The patient underwent an open-suture cruroplasty and had an unremarkable recovery. 

Hiatal hernias are classified into 4 subtypes. Sliding hiatal hernia (type I) is most common and is caused by upward migration of the esophagogastric junction into the mediastinum.¹ Paraesophageal hernias account for less than 10% of all hiatal hernias¹ and may involve upward dislocation of the gastric fundus alongside the cardia (type II), enlargement of the hiatus (type III), or abdominal organ movement into the hernia sac (type IV). Paraesophageal hernias are found predominantly in elderly women with multiple comorbidities.² Patients are either asymptomatic or have minor symptoms such as epigastric fullness, postprandial distress, regurgitation, or hematemesis.² For diagnosis, radiography is preferred over computed tomography because retrocardiac air bubbles are more easily seen on a radiographic image. Massive incarcerated paraesophageal hernias require emergent surgical intervention.³