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A 92-year-old man presented in extremis with respiratory failure. His chest X-ray (CXR) (figure 1A) showed right lower zone opacification and an intrathoracic gastric bubble. Emergency CT showed a giant paraoesophageal hiatal hernia containing his stomach, spleen and transverse colon (figure 1B,C). Nasogastric drainage failed to decompress the stomach; which had undergone volvulus.