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A 92-year-old man with hypertension and atrial fibrillation presented with abdominal
pain and fever for 1 day. On physical examination, bowel sounds were heard over the
right infra-axillary region; the abdomen was scaphoid, soft, with suprapubic tenderness.
An initial upright chest radiograph showed marked distortion of the cardiomediastinum
due to large gas-containing structures in the lower portion of the thorax ( Figure A). A computed tomogram of chest and abdomen (Figure B) showed a type 4 hiatal
hernia with intrathoracic herniation of the stomach (white arrow) and part of the
small and large bowel (star). Urinalysis confirmed a urinary tract infection, and
the patient improved with ceftriaxone. Given the asymptomatic nature of the hiatal
hernia and old age of the patient, decision was taken to forgo any surgical intervention.
