A 50 year old man was admitted with severe epigastric pain. He had previously had an open Heller's cardiomyotomy for achalasia. Subsequent investigations for persisting dyspepsia had demonstrated a rolling hiatus hernia. He was tachycardic and hypotensive, with a raised jugular venous pressure. His chest radiograph showed bowel loops within the left hemithorax and a left pleural reaction.

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An urgent transthoracic echocardiogram revealed that the atria were obscured by an extracardiac mass. A diagnosis of extrinsic cardiac compression secondary to a gastric volvulus was made. While awaiting emergency surgery his condition deteriorated culminating in electromechanical dissociation (EMD). Following successful resuscitation there was an immediate improvement in his blood pressure. At surgery he had a tight, scarred hiatus below which only the pylorus was visible. The stomach was brought down into the abdomen, and an anterior gastropexy performed. He was discharged 12 days later and is well at six month follow-up.

There are few reported cases of gastrointestinal causes of extrapericardial cardiac compression producing haemodynamic compromise. We believe this is the second report involving a gastric volvulus. The echocardiographic features of diaphragmatic herniae have been previously characterised, with the hiatus hernia usually being visualised as an amorphous solid mass compressing the atria. We postulate that, in our case, there was significant compression of both atria causing tamponade. Although the patient suffered an EMD cardiac arrest, the physical act of cardiac massage may have resulted in partial decompression of the volvulus, since the haemodynamic parameters were much improved immediately postarrest.