Hiatal hernias are classified into four types. Type 4 hernias are not limited to the stomach alone, but involve herniation of the omentum, colon, small intestine, peritoneum, pancreas, or spleen into the chest cavity. Account for less than 5% of all cases. The probability that a patient with a paraesophageal hernia will develop acute symptoms and require emergency surgery is 1.16% per year. We present a case of acute paraesophageal hiatal hernia repair in a patient who developed large bowel obstruction. An 82-year-old female was admitted to emergency room referring abdominal distension, intolerance to the oral intake, vomiting of fecal content, as well as impossibility to pass gas or evacuate. On physical evaluation with tachycardia and acute abdomen, laboratory studies showed leukocytosis, radiographic data of intestinal obstruction, and at the level of the left hemithorax, space occupation by the colon was evident. An emergency surgery was performed finding paraesophageal hernia with involvement of the stomach and transverse colon, and retrograde dilatation of the ascending and transverse colon with ischemic changes. The patient presented hemodynamic instability, so an extended right hemicolectomy was decided, with distal closure, ileostomy, and hiatal plasty performed. She was discharged on postoperative day four without complications. Type 4 hiatal hernia complicated with intestinal obstruction is a condition that carries high rates of morbidity and mortality, so early surgery is mandatory to avoid a fatal outcome for the patient. There are currently no clear guidelines regarding the management of acute complicated paraesophageal hernias.