A fifty-four-year-old man was admitted to the acute medical unit with central chest pain radiating to his throat. His initial investigations including ECG and cardiac enzymes were within the normal range. His chest X-ray was also considered to be normal, initially (Figure 1). Due to his risk factors for ischaemic heart disease (smoking and hypertension), he was started on anti-platelets and low molecular weight heparin that resulted in deterioration of his symptoms and coffee ground vomiting.
Figure 1. PA chest x-ray film that was initially thought to be normal
Upon re-revisiting the history, he described his chest pain as burning sensation associated with food with no exertional component. His chest x-ray was also re-examined, it showed a large hiatus hernia represented by a rounded shadow with an air-fluid level visible behind the heart (Figure 2). Further cardiac investigations were found to be normal and upper GI endoscopy confirmed a hiatus hernia with reflux- gastritis. He was treated with high dose proton pump inhibitors leading to a complete resolution of his symptoms. A careful history taking, and review of chest x-ray may reveal the cause of central chest pain in some patients; historically helpful hint from radiologists ‘look behind the heart’ still holds true.
Figure 2. PA – chest x-ray showing a large hiatus hernia with an air-fluid level behind the cardiac shadow (arrow)
