A 76-year-old man was admitted to the hospital with nonexertional epigastric pain radiating to the lower chest. His medical history included gastroesophageal reflux disease. Plain-film (single view) radiographic chest images demonstrated a large hiatal hernia (image A). A nothing-by-mouth diet was prescribed, but the patient continued to have significant epigastric discomfort. Nasogastric intubation resulted in drainage of 3 L of gastric secretions. Computed tomographic images without contrast demonstrated a large strangulated paraesophageal hernia (image B, arrow). The patient underwent robotic-assisted laparoscopic repair of the hernia with surgical mesh. His postoperative course was complicated by sepsis, which resolved after a short course of cefepime. 

Paraesophageal hernias are less common and more severe than sliding hernias. Symptoms may include chest pain, abdominal pain, or respiratory distress. The rate of progression to symptoms is about 14% per year.¹ Complications include obstruction, bleeding, strangulation, perforation, respiratory compromise, and gastric volvulus.¹ All symptomatic and any complicated paraesophageal hiatal hernias should be surgically repaired, usually laparoscopically.¹ Surgical repair improves quality of life and mortality rates,² and recurrences are rare.³