The finding of an airfluid level in the left lower chest with a nasogastric tube entering it after blunt trauma to the abdomen is diagnostic of diaphragmatic rupture with gastric herniation into the chest. This lesion needs to be fixed immediately.With continuing negative pressure in the chest, each breath sucks more of the abdominal contents into the chest and increases the likelihood of vascular compromise of the herniated viscera. While the diaphragm is easily fixed from the left chest, this injury should be approached from the abdomen. The possibility of injury below the diaphragm after sufficient blunt injury to rupture the diaphragm mandates examination of the intra-abdominal solid and hollow viscera; adequate exposure of the diaphragm to allow secure repair is possible from this approach.