Intramural esophageal hematoma is a very rare but important cause of chest pain. This condition shares similarity with the diagnosis of other thoracic emergencies and has a high potential for misdiagnosis. The emergency clinician plays a critical role in the early identification and management of these patients. The management of intramural hematomas is typically conservative, and a misdiagnosis could lead to deleterious effects. Preexisting coagulopathy is one of the major risk factors. With the advent of new anticoagulation medications to prevent thromboembolic events, it is important that emergency medicine providers expand the differential diagnosis of chest pain.