For 2 years, a 79-year-old man had postprandial fullness and epigastric discomfort. He also experienced regurgitation and substernal pain after eating that was relieved by belching. He had a history of hypertension and gout. The patient’s vital signs were normal. Laboratory test results were within normal limits. A chest radiograph showed haziness with an airfluid level in the left costophrenic angle, close to the cardiac apex (A). Results of an upper GI barium swallow study revealed a paraesophageal hernia (B). A portion of the stomach was seen in the intrathoracic position. Virendra Parikh, MD, of Fort Wayne, Ind, writes that paraesophageal hernias are more common with advanced age. Most are asymptomatic when discovered early. Symptoms of pain, fullness, and eructation are intermittent and episodic. Chronic anemia from gastritis is common. Substernal pain may be confused with cardiac angina; a nitroglycerin trial can rule out this entity. All patients with this type of hernia are at risk for obstruction and strangulation of the herniated stomach. Paraesophageal hernias require surgical repair. This can be done by laparoscopic method, laparotomy, or thoracotomy. The likelihood of recurrence is small (less than 5%). This patient recovered well after surgery.