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.