Paraesophageal hernias are usually classified into three distinct types: type I, sliding hernias; type II, paraesophageal hernias; type III, a combination of type I and II. Herniation of other abdominal organs can be classified as type IV, and is a rare situation at the esophageal hiatus. We report herein a 73-year-old female patient who presented with epigastric pain and diagnosed as type IV paraesophageal hernia. Initial evaluation was focused on myocardial ischemia. There was no evidence of myocardial ischemia in the coronary angiography, but follow-up chest X-ray revealed air-fluid levels in the left mediastinum suggested hiatal hernia. On computed tomography, herniation and strangulation of proximal jejunum into the hemithorax via left diaphragmatic defect was found. After reduction of small bowel and resection of strangulated segment, the defect was closed. Fluid collection in the hernia sac was detected at postoperative day nine, but she was discharged without complication.