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Gastric volvulus and paraoesophageal hernia treatment in Ahmedabad · Gota OPD, Ahmedabad · Apollo Hospital, Bhat, Gandhinagar
When part of the stomach has slipped up beside the food pipe into the chest, two very different situations can follow. If the stomach twists on itself and its blood supply is cut off — acute gastric volvulus — it is an emergency measured in hours, and the treatment is an operation the same day. If the large hernia sits quietly and causes no symptoms, current guidance supports watching it rather than operating, provided you know exactly what a twist feels like. Between these two lie the patients whose hernia causes pain, vomiting, anaemia or breathlessness, for whom a planned repair is offered.
A twisted stomach needs a surgeon, an anaesthetist, a CT scanner, an endoscopist and an intensive care bed within hours; a quiet large hernia needs a careful clinic discussion and, sometimes, nothing more. At Apollo Hospital, Bhat, the emergency side is one service, and the same surgeon sees planned patients at the Gota clinic — so the decision to operate, to anchor or to watch is made by the person who would carry it out.
Shah’s Gastro, Cancer & Robotic Surgery Centre. Trained in super-specialty surgical gastroenterology programmes, qualified twice over in the specialty, with 18 years of experience in surgery of the stomach and food pipe. Emergency CT and endoscopy, intensive care, keyhole and open stomach surgery, endoscopic gastropexy, dietitian support and follow-up sit within one practice.
Dr Harsh Shah
MS, MCh (Surgical Gastroenterology), DrNB (Surgical Gastroenterology)
Registered with Gujarat Medical Council, Reg. No. G-38738
Stomach Surgeon · Apollo Hospital, Bhat, Gandhinagar · Gota OPD, Ahmedabad
Google rating 4.89 from 216 reviews at the Gota clinic, and 4.94 from 18 reviews at Apollo, Bhat.
The diaphragm has a natural opening through which the food pipe passes into the abdomen. In a common sliding hiatus hernia, the junction of the food pipe and stomach slides up through it — mainly a reflux problem. In a paraoesophageal hernia, the upper part of the stomach rolls up beside the food pipe into the chest; in the mixed kind, both happen, and this mixed kind is the commonest large hernia seen in practice. Occasionally the colon, spleen or small bowel follows the stomach into the sac. A stomach lying in the chest can rotate — around its long axis, from the upper end of the stomach to its outlet, or around its short axis — and that rotation is a gastric volvulus.
Three signs together mean a twisted stomach until proven otherwise: sudden, severe pain in the upper abdomen or lower chest; violent retching with an inability to actually vomit; and a nose tube that will not pass into the stomach. In someone known to have a hiatus hernia, this combination is a surgical emergency.
Distress out of proportion to what the examination shows, a racing pulse and steady worsening are added warnings. The danger is strangulation: once the twist cuts off the blood supply, the stomach wall can die and burst within hours, and the risk to life rises sharply once that has happened. A twisted stomach is therefore never “observed overnight”. Treatment — fluids, pain relief, a careful attempt at decompression and urgent surgery — starts as soon as the diagnosis is suspected.
Not every volvulus is this dramatic. A twist around the short axis is often intermittent: bouts of upper abdominal pain, fullness and retching after meals that settle on their own. These episodes are a reason for a planned repair rather than continued watching.
A large paraoesophageal hernia often causes pain or pressure in the chest or upper abdomen after meals, early fullness, bloating, difficulty swallowing, reflux or regurgitation, and breathlessness when a large part of the stomach lies in the chest. Many cause no symptoms at all and are found by chance on a chest X-ray or a CT done for something else.
One presentation is easily missed: iron-deficiency anaemia. As the stomach rubs up and down through the tight opening in the diaphragm, long shallow erosions called Cameron lesions form on its folds and bleed slowly. Tiredness and breathlessness from anaemia, with no obvious source of bleeding, can be the only clue to a large hernia. An anaemia that keeps returning despite iron is one of the reasons repair becomes worthwhile.
A CT of the chest and abdomen with contrast is the key test: it shows the type of hernia, what has gone into it, whether and how the stomach has twisted, and any sign that the stomach wall is losing its blood supply. A chest X-ray may give the first clue; a contrast swallow maps the anatomy in a stable patient; and an endoscopy looks at the lining — but never delays surgery in an unstable patient.
| Test | When | What it decides |
|---|---|---|
| CT chest and abdomen with contrast | First, in the emergency and in the planned setting | Hernia type and contents, the axis of any twist, and warning signs of a dying stomach wall — thinning, poor enhancement, air in the wall or free air |
| Chest X-ray | Often the first film taken | A gas-and-fluid level behind the heart that raises the suspicion |
| Upper GI contrast study | Stable patients | The shape of the hernia and the rotation of the stomach |
| Upper GI endoscopy | Planned patients; in the emergency only if it does not delay surgery | The state of the lining, Cameron lesions, and exclusion of a growth; may be difficult or impossible in a twisted stomach |
| Blood counts, iron studies, salts, lactate | Every patient | Anaemia and its cause; dehydration; a rising lactate that suggests the stomach is suffering |
| Manometry (pressure study of the food pipe) | Before a planned repair when a wrap is intended and a motility disorder is possible | Whether a full or partial wrap is safe, and whether achalasia is present |
A paraoesophageal hernia and a gastric volvulus are mechanical, benign problems. The endoscopy is still important, because a growth in the stomach or at the junction with the food pipe can cause pain, vomiting, anaemia and weight loss that look the same — and it changes the treatment completely.
That is why a planned patient has an endoscopy with biopsy of anything unusual before repair, and why bleeding is not simply blamed on Cameron lesions until the rest of the lining has been seen. In the emergency, the operation itself shows the stomach directly, and any area that is not healthy is examined in the laboratory.
For a suspected twist, the steps are resuscitation with fluids, salt correction and pain relief; a careful attempt to pass a nose tube to decompress the stomach — never forced; antibiotics if strangulation is suspected; and an urgent operation, without a period of watching.
If the nose tube does pass and the stomach empties, the pressure falls and an emergency can become an urgent operation done in better conditions, but it does not replace surgery. At operation the stomach is brought back into the abdomen and untwisted, and then given time — its colour and blood flow are checked again after a pause, exactly as with any twisted bowel, before anything is removed.
| What is found | What is done |
|---|---|
| Stomach healthy after untwisting, patient stable | Return to the abdomen, removal of the hernia sac, closure of the opening in the diaphragm, and anchoring of the stomach (gastropexy), with or without a wrap |
| Stomach healthy, patient elderly or unstable | A deliberately limited operation: untwisting and anchoring only — better judgement than an elaborate repair |
| Part or all of the stomach has died | Removal of the dead stomach (partial or total gastrectomy) with reconstruction — a major and high-risk operation |
| Stomach has burst | Removal of the damaged part, washout, and a decision between reconstruction now and a staged approach |
For a frail patient who is not fit for an immediate major operation, the stomach can be untwisted through an endoscope and then fixed to the front of the abdominal wall with two feeding-tube anchors placed through the skin (endoscopic reduction with double PEG gastropexy). This is an established, less invasive option that holds the stomach in place and prevents it twisting again — for the right patient, it is the considered choice rather than a compromise.
A large paraoesophageal hernia that causes no symptoms does not automatically need an operation. Current guidance from the American surgical society (SAGES, 2024) supports watching it, which reverses the older teaching that every large hernia should be repaired to prevent a twist. The risk of a sudden emergency is lower than was once thought, and planned repair carries real risks and a real chance of the hernia showing again on later X-rays.
Watching is an active plan, not a dismissal. The patient and family are told in writing what a twist feels like — the sudden severe pain, retching without vomiting, inability to keep anything down — and that it means going to an emergency department at once, not waiting for a clinic. Meals are kept small and frequent, lying flat after a large meal is avoided, an acid-reducing tablet treats reflux and helps Cameron lesions heal, iron is replaced, and the anaemia is re-checked after treatment. If symptoms develop, or the anaemia comes back despite iron, the decision is re-opened.
An incidental large hernia in an older person who feels well is the classic case in which watching is the better judgement. That conversation is had openly at the consultation, with the reasons for not operating explained as carefully as the reasons for operating would be.
A planned repair is offered for a hernia that is causing significant symptoms — difficulty swallowing, pain after meals, early fullness, vomiting or breathlessness — and for blockage of the stomach outlet, severe reflux not controlled by tablets, severe or recurrent iron-deficiency anaemia, episodes that sound like an intermittent twist, and any sign of possible strangulation, which makes it urgent.
Every repair is discussed in advance with the patient, the family and, where useful, the anaesthetist and physician. Before a planned operation, nutrition is built up, iron is replaced, smoking is stopped, weight is reduced where possible because excess weight raises the chance of the hernia coming back, and breathing is optimised — a large stomach in the chest compromises the lungs.
A planned repair is usually a keyhole operation. The stomach is brought back into the abdomen, the hernia sac is removed completely from the chest, the food pipe is freed until a good length lies in the abdomen without tension, the opening in the diaphragm is closed, and a wrap and anchoring stitches hold the stomach where it belongs.
| Step | Why it matters |
|---|---|
| Bring all contents back into the abdomen | The stomach and any other organ return to their normal place |
| Remove the whole hernia sac from the chest | A key step that is often done incompletely; a sac left behind invites the hernia back |
| Free the food pipe in the chest | Enough food pipe must lie in the abdomen without tension — too short a length is the commonest cause of the hernia returning |
| Lengthen the food pipe (Collis) only if needed | For a truly short food pipe that cannot be brought down far enough |
| Close the opening in the diaphragm from behind | Without tension, with relaxing cuts if needed |
| Wrap (fundoplication) | Controls reflux and helps anchor the stomach; full or partial depending on the food pipe’s squeeze |
| Mesh — case by case | The 2024 guidance made no recommendation for or against mesh; if one is used, the reason is written down, because mesh can erode or narrow the food pipe |
| Gastropexy (anchoring the stomach) | A useful addition, and in a frail patient an alternative to the full repair |
Keyhole repair is the standard approach. A robotic approach is appropriate in experienced hands, and open or chest approaches are kept for difficult anatomy or repeat operations. An endoscopy on the table may be used to check the wrap and confirm there is no injury.
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“Excellent doctor. I have undergone Surgery for toupet fundoplication with harsh Shah doctor. Sir has given good treatment for early recovery. Treating patients very friendly. — Ravi Bob, Google review, Gota clinic listing”
★★★★★
“Dr. Harsh Shah is an excellent doctor who handled our case with great diligence and care. He listens attentively and addresses every concern with utmost patience. He's very humble and answers all of your questions in detail which is very assuring. I would highly recommend Dr. Harsh Shah for consultation and treatment. — Srinath Vasudevan, Google review, Gota clinic listing”
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“He is simple and straight conversation person. Explains the procedure and process to prepare the patient mentally for the surgery which makes patients comfortable during the process. He is also very patient enough to hear all problems of his patients which makes him an approachable doctor. — palak thareja, Google review, Gota clinic listing”
Real Google reviews from Dr Harsh Shah’s two listings, reproduced exactly as written.
After a planned keyhole repair, patients sit out of bed the same day, take free fluids the next day and usually go home on the second or third day on a staged diet — liquids, then soft food, then normal textures over several weeks — with a dietitian guiding each step. After an emergency operation, recovery depends on how much stomach was saved, and may begin in intensive care.
Retching can disrupt a fresh repair, so anti-sickness medicines are given generously and continued at home. Heavy lifting and straining are avoided in the early weeks. A contrast study is done after the operation only if there is a clinical reason. Iron is continued where anaemia was the reason for surgery. Fever, a racing pulse, chest pain, inability to swallow saliva, breathlessness or retching are reasons to contact the team at once.
After removal of the whole stomach in an emergency, eating changes for life: smaller, more frequent meals, dietitian support, and regular vitamin B12 injections.
A planned repair carries real risks, and one fact is starred in every consent discussion: the hernia is often seen again on a later X-ray, although most of these returns are small and cause no symptoms, and only a minority need another operation. An emergency operation for a dead stomach carries a high risk to life. Dr Harsh Shah gives the figures that apply to each patient at the consent discussion.
Planned repair: bleeding, infection, clots in the leg or lung, heart or breathing complications, conversion from keyhole to open surgery, injury to the food pipe or stomach, air or fluid around the lung (usually managed without a drain), difficulty swallowing that is common early and usually settles, bloating with difficulty belching or vomiting after a wrap, slow stomach emptying, problems from mesh if mesh is used, and the hernia returning. Emergency operation: leak from any join, chest complications, the need for critical care, and — if the stomach had died — the effects of partial or total removal of the stomach. In a frail patient, a smaller untwist-and-anchor operation may be chosen deliberately as the safer path.
Follow-up is based on symptoms, not routine X-rays. The checks are at two to six weeks (wound, diet stage, swallowing, dietitian input), at three months (symptoms, weight and iron studies where anaemia was the reason) and at six to twelve months. An X-ray is not repeated in someone who is well, because a small return found by chance rarely changes anything and often causes needless worry.
New symptoms after repair — reflux, pain, swallowing difficulty or anaemia — lead to a contrast study and endoscopy, and most small returns are treated by easing symptoms first. Any further operation is discussed fully beforehand. Patients with mesh report new swallowing difficulty, bleeding or pain promptly. Patients whose hernia is being watched keep their written warning-sign sheet and are reviewed in clinic.
The cost of a planned repair depends on the approach, whether mesh is used and the length of stay. An emergency operation depends on what is found, days in intensive care and the length of stay. Watching a hernia costs the consultations and tablets. A written estimate is given and explained.
Apollo Hospital, Bhat, works with the major insurers and cashless schemes, and the office handles pre-authorisation directly; an emergency admission is notified to the insurer at the time, and if a stay runs longer than estimated an enhancement request is raised then rather than at discharge.
Bring: CT images on a disc or drive with the report, endoscopy reports and photographs, any contrast-study images, recent blood counts and iron studies, a list of medicines including blood thinners, discharge papers from any earlier hernia operation, the insurance card and identification.
Not automatically. Current guidance supports watching a large paraoesophageal hernia that causes no symptoms. You will be told exactly what a twist feels like and to go to an emergency department at once if it happens; the decision is re-opened if symptoms or anaemia appear.
Sudden, severe pain in the upper abdomen or lower chest, violent retching with nothing coming up, and often being unable to swallow anything. In someone with a known hiatus hernia, this needs emergency care straight away.
A nose tube may relieve the pressure and buy time, but it does not replace an operation. In a frail patient, the stomach can be untwisted through an endoscope and anchored with two feeding-tube fixings through the skin.
Only case by case. The 2024 surgical guidance made no recommendation for or against mesh, so if mesh is used for you, the reason is explained and recorded.
It is often seen again on later X-rays, but most such returns are small and cause no symptoms. That is why follow-up is based on symptoms rather than routine X-rays.
The stomach rubbing through the tight opening in the diaphragm can form shallow erosions that bleed slowly. If anaemia keeps returning despite iron, it strengthens the case for repair.
Shah’s Gastro, Cancer & Robotic Surgery Centre — Gota, Ahmedabad
Consultations, review of CT and endoscopy, follow-up after repair and for watched hernias.
Google: Dr Harsh Shah · 4.89 from 216 reviews
Directions to the Gota clinic · +91-63555-64601
Apollo Hospital — Bhat, Gandhinagar
Apollo Hospital International Limited, Plot No. 1 A, GIDC Bhat Industrial Estate, Bhat, Gandhinagar.
Google: Dr Harsh Shah – Robotic GI Surgeon · 4.94 from 18 reviews
Directions to Apollo, Bhat · WhatsApp +91-63555-64601
Patients come to Ahmedabad for stomach surgery from across Gujarat — Gandhinagar, Mehsana, Banaskantha, Nadiad, Anand, Bhavnagar, Rajkot, Jamnagar and Kutch — and from southern Rajasthan and western Madhya Pradesh.
Sudden severe pain in the upper abdomen or lower chest, with violent retching that brings nothing up? Go to the nearest emergency department now — this cannot wait for a reply. For a large hiatus hernia found on a scan, or symptoms that come and go, the CT, endoscopy and contrast-study reports and recent blood counts can be sent ahead of the appointment, so the consultation starts with them already read; treatment is decided at the consultation, after examination. Call +91-63555-64601 · Send the reports ahead on WhatsApp
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