A 24 year old paint gelding presented for an acute abdomen with a history of two colic episodes in the previous month. The initial episode of pain resolved with administration of 600mg of Flunixin Meglumine on the home farm. During the second episode of colic 600mg of Flunixin Meglumine was given but the pain was not able to be controlled and the patient was referred to Cornell University. The horse was not up to date on vaccinations and had not been dewormed recently. Upon arrival the horse was tachycardic and mildly tachypnic. The patient was managed medically overnight on intravenous fluids, a lidocaine continuous rate infusion, sedation, and oral fluids via nasogastric intubation. The colic episode resolved and an ultrasound of the thorax revealed a diaphragmatic hernia with confirmed small intestine in the thoracic cavity. The gelding went home under conservative management and experienced another severe colic episode three weeks later, at which time euthanasia was elected.