Tehran University of Medical Sciences Archives of Anesthesiology and Critical Care 2423-5849 10 2 2023 12 27 191 193 EN Abhishek Samprathi Critical Care Services, Narayana Institute of Health Sciences, Bengaluru, Karnataka, India. Nischal Pandey Cardiothoracic surgery department, Fortis Hospitals, Bengaluru, Karnataka, India. Padmakumar Arayamparambil Department of Critical Care Medicine, Fortis Hospitals, Bengaluru, Karnataka, India. 2023 03 23 2023 04 18 Diaphragmatic hernias are rare and mostly congenital, rarely spontaneous. Perforation and other complications of diaphragmatic hernias are even rarer and associated with significant morbidity and mortality. We report a patient presenting to the emergency department with features of empyema requiring intercostal drainage. However, on clinical worsening, radiological imaging showed features of diaphragmatic hernia and a subsequent thoracostomy revealed a herniated gastric perforation. Such cases are very rare and need a high index of suspicion for the diagnosis and early appropriate surgical management. Otherwise, it is associated with very high rates of mortality. https://aacc.tums.ac.ir/index.php/aacc/article/view/728