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DIS 5.5.0 DTD YGAST61126 proof 23 November 2017 5:39 pm ce G 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 Question: A 63-year-old woman was admitted to the emergency room for vomiting and abdominal pain localized in the epigastric region for the past 48 hours. Past medical history included ulcerative colitis, arterial hypertension, and asthma. Four months before admission, she had complained of occasional episodes of epigastric pain and had undergone an esophagogastroduodenoscopy (EGD) that had revealed a parahiatal hernia with an intrathoracic 88 89 90 91 92 93 94 95 96 97 98 fundus and gastric corpus. She had a computed tomography scan that an revealed immense hiatal hernia, without signs of torsion. On physical examination at admission the patient was apyretic, her blood pressure was 179/110 mm Hg, pulse rate was 92 beats/min, and her respiratory rate was 18 breaths/min. Epigastric tenderness was noted with no palpable abdominal mass or organomegaly, and abdominal sounds were present. Blood test results revealed a normal hemoglobin (14 g/dL), leukocytosis (12.7 10 cells/mm) with neutrophilia (84%), hypokalemia (3.1 mEq/L), a slightly elevated C-reactive protein (2.09 mg/dL), and normal liver tests. There was an unsuccessful attempt to place a nasogastric tube. An abdominal radiograph revealed 2 large air bubble signs in the chest (Figure A). EGD was performed (Figure B). What is the most likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 99 100 101 102 103 104 105 Conflicts of interest The authors disclose no conflicts.