Spontaneous intramural hematoma of the esophagus (SIHE) is a rare condition usually affecting middle-aged or elderly women. It presents as acute substernal or epigastric pain, typically accompanied by dysphagia or hematemesis. SIHE is not usually associated with vomiting, and is therefore clearly distinguished from emetogenic esophageal disorders, such as the Mallory-Weiss lesion and the Boerhaave syndrome. The diagnosis has traditionally been made by barium esophagram. Therapy is conservative; a favorable prognosis is the rule. The pathogenesis is in dispute. We present a case of SIHE without a discernible mucosal breach, suggesting a primary intramural bleed as the initiating event. We document the utility of computed tomographic scan and magnetic resonance imaging in the diagnosis of SIHE.