An 81-year-old woman was admitted with a 1-week history of breathlessness. On admission, she was found to be in respiratory distress with new onset atrial fibrillation and hypotension. Her chest X-ray (Fig. 1) revealed a large hiatus hernia with a dual-fluid level, associated with significant extension into the left hemithorax and mediastinal shift. She was admitted to a general medical ward, where care was focused on controlling her atrial fibrillation. Overnight, she developed hypoxaemia and was found to be in severe type 2 respiratory failure. Following a review of her chest X-ray, she was referred for urgent laparotomy, which disclosed an incarcerated hiatus hernia with extensive mucosal necrosis. Following partial gastrectomy and supportive care, she made a steady recovery. Although hiatus herniae are common, incarceration is a rare complication of paraoesophageal herniae. Patients presenting with such features on chest X-ray, even in the absence of gastric outlet obstruction, should be referred for urgent surgical intervention.

Fig. 1
figure 1

Chest X-ray revealing a large hiatus hernia with a dual-fluid level, associated with significant extension into the left hemithorax and mediastinal shift

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