Case of the Month

The presence of free air within a hiatal hernia sac is an uncommon reported entity. This finding has been described in the surgical literature1-4 secondary to incarcerated hiatal hernias complicated by gastric ulceration and perforation. There have, however, been no reports of this entity in the radiology literature. Our patient presented to the emergency department complaining of epigastric pain following recent laparoscopic inguinal hernia repair. Conventional radiographs demonstrated findings suspicious for pneumopericardium. An emergent MSCT study was performed, which demonstrated free air surrounding a large hiatal hernia. This case demonstrates the MSCT features of pneumoperitoneum surrounding a hiatal hernia and discusses the importance of this finding when associated with a bowel perforation.