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.
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The authors have no financial or other conflicts of interest to disclose.
© 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.