From Silent to Severe: Gastric Perforation Causing Spontaneous Hydropneumothorax Secondary to a Large Hiatal Hernia.

Hiatal hernias, characterized by the protrusion of internal organs through the diaphragmatic hiatus, are commonly seen in the elderly age group. While surgical management remains debatable for asymptomatic cases, emergent complications necessitate prompt intervention. Here, we present a case of a 69-year-old female with a history of diaphragmatic hernia, who developed acute hypoxic respiratory failure secondary to acute pleural effusion caused by paraesophageal hernia rupture. Despite initial inconclusive imaging, a CT scan revealed the severity, prompting emergent management. The patient underwent esophageal stent placement, video-assisted thoracoscopic surgery-assisted total lung decortication, and three chest tubes placement, followed by antimicrobial therapy. Favorable outcomes were achieved with multidisciplinary intervention, highlighting the importance of timely recognition and comprehensive diagnostic approaches. This case underscores the potential severity of hiatal hernias, particularly paraesophageal types, necessitating vigilance among clinicians for timely intervention. It also emphasizes the effectiveness of combined surgical and medical multidisciplinary approaches in such emergent situations for optimal patient outcomes.