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An 88-year-old former smoker with chronic dyspnea related to emphysema and epigastric discomfort attributed to gastroesophageal reflux and a hiatal hernia presented to the emergency department with left-sided chest pain and worsening shortness of breath. Blood pressure was 100/58 mm Hg; pulse rate, 109 beats per minute, and respiration rate, 24 breaths per minute. Heart sounds were unremarkable, and breath sounds were reduced bilaterally. Electrocardiography showed sinus tachycardia and a QRS pattern consistent with old anterior infarction. Chest radiography showed normal heart size, right lung bullous abnormalities, and a left-sided pneumothorax, which was treated with a thoracic vent, resulting in reexpansion of the lung.

Two days later, the patient developed severe epigastric and lower chest pain and was diaphoretic and hypotensive; blood pressure was 56/44 mm Hg. Electrocardiography showed new marked left-axis deviation. The chest radiograph (Figure 1) showed no recurrent pneumothorax, but air was present around the cardiac silhouette.

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Figure 1. Chest radiograph showing air adjacent to the heart (white arrows). Computed tomography subsequently showed that this air was actually in the stomach, which had prolapsed into the chest through a large hiatal hernia.

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Contrast computed tomography (CT) showed a hiatal hernia with an intrathoracic stomach (Figure 2, Figure 3, Figure 4, and Figure 5), which displaced the heart anteriorly, compressing the left atrium. Removal of fluid and gas using a nasogastric tube resulted in prompt resolution of symptoms and restoration of normal blood pressure.

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Figure 2. Axial computed tomographic image through the mid-chest showing displacement and compression of the heart by a large hiatal hernia containing the stomach filled with air and fluid. LV indicates left ventricle.

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Figure 3. Axial computed tomographic image from a different patient than shown in Figure 2, illustrating the right ventricle (RV) and left ventricle (LV) and more subtle abnormalities of the esophagus. The walls of the esophagus (white arrow) are thicker than normal, suggesting chronic reflux.

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Figure 4. Coronal computed tomographic image from the same patient shown in Figure 3, again showing thickened walls of the esophagus (white arrows).

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Figure 5. Coronal image showing a small hiatal hernia containing elements of the stomach, displacing the thoracic aorta. The left atrium is not compressed in this patient.

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CT is a powerful tool for evaluating chest pain, dyspnea, and hypotension. While coronary artery disease is the most common life-threatening etiology of chest pain, CT allows comprehensive evaluation of not only the heart and coronary arteries but also the aorta, pulmonary arteries, lungs and, as in this case, gastrointestinal causes of chest pain and hypotension.

Hiatal hernias are quite common and are commonly seen on CT images primarily obtained to evaluate patients for cardiac disease. Such hernias can be asymptomatic and represent incidental findings of little clinical significance, but in other cases, symptoms of epigastric or substernal pain, post-prandial pressure or fullness, and nausea can mimic cardiac symptoms. Complications of a hiatal hernia include gastric volvulus, bleeding from gastric ulceration or erosion, and compression of the lungs or even the heart, as in this case.