Question: An 87-year-old woman with history of dementia, atrial fibrillation, hypertension, and gastroesophageal reflux disease presented with abdominal pain. CT demonstrated abnormal location of a portion of the pancreas (Figure A–D, arrowheads) and dilation of the corresponding segment of the main pancreatic duct (arrows) on transverse and coronal images. A 3-dimensional, volume-rendered image from subsequent MR cholangiopancreatography examination demonstrated abnormal course of pancreatic duct, along with localized pancreatic ductal narrowing (small arrows) and segmental dilation (large arrows) (Figure E). Laboratory tests done on the same day as the CT examination revealed lipase of 116 U/L (normal range, 20–300), aspartate aminotransferase 19 U/L (normal range, 2–44), alanine aminotransferase 28 U/L (normal range, 0–54), alkaline phosphatase 64 U/L (normal range, 50–135), and total bilirubin 0.8 mg/dL (normal range, 0.2–1.0). What is the etiology for the abnormal appearance of the pancreatic duct? Look on page 293 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The CT images demonstrate a type IV hiatal hernia, containing a portion of the pancreatic body in addition to the stomach. There is resultant relative focal narrowing of the main pancreatic duct at both the entry and exit sites through the diaphragmatic hiatus, and dilation of the pancreatic duct in the intervening superiorly herniated segment of the pancreas. Differential diagnosis for the imaging findings also potentially includes pancreatic malignancy, sequelae of pancreatitis, and segmental main duct intraductal papillary mucinous tumor. Superior herniation of the pancreas via the diaphragmatic hiatus can be an incidental finding, but associated occurrence of pancreatitis has also been reported, with proposed mechanisms for pancreatitis, including pancreatic injury from repetitive pancreatic movement, vascular compromise, volvulus, as well as intermittent obstruction or folding of the pancreatic duct.1Gremmels J.M. Broome D.R. Fisher K.L. Pancreatic herniation through the gastroesophageal hiatus: magnetic resonance imaging, magnetic resonance cholangiopancreatography, and computed tomography evaluation.J Comput Assist Tomogr. 2003; 27: 616-618Crossref PubMed Scopus (8) Google Scholar, 2Chevallier P. Peten E. Pellegrino C. et al.Hiatal hernia with pancreatic volvulus: a rare cause of acute pancreatitis.AJR Am J Roentgenol. 2001; 177: 373-374Crossref PubMed Scopus (23) Google Scholar In the presented case, given the advanced age of the patient, normal lipase level, and stable appearance of the pancreas compared to a prior CT scan done 2 years earlier, the patient was managed conservatively.