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Condition Deep-Dive

Hiatal Hernia

A hiatal hernia occurs when part of the stomach pushes up through the diaphragm into the chest cavity, disrupting the lower esophageal sphincter and creating chronic acid reflux, GERD, and digestive dysfunction. It affects over 20% of adults — and most are managed with acid-suppressing drugs that address symptoms, not causes.

20%+ of Adults GERD Connection Diet-Responsive
Definition

What Is a Hiatal Hernia?

A hiatal hernia occurs when the upper portion of the stomach herniates (pushes upward) through the hiatus — the opening in the diaphragm through which the esophagus normally passes. This disrupts the anatomical barrier between the stomach and esophagus, allowing acid and stomach contents to reflux freely.

The lower esophageal sphincter (LES) — the muscular valve that normally prevents acid from flowing back into the esophagus — relies partially on the diaphragm for mechanical support. When the stomach herniates above the diaphragm, this support is lost, and even a competent LES may fail to prevent reflux.

The condition is far more common than recognized — an estimated 55–60% of people over 50 have some degree of hiatal herniation, with the majority having no symptoms. However, when symptomatic, it creates a cascade of digestive dysfunction that affects quality of life profoundly.

⚠️ Long-term acid suppression with PPIs (the standard treatment for hiatal hernia/GERD) depletes vitamin B12, magnesium, iron, and calcium; increases risk of C. difficile, SIBO, and Candida; and is associated with accelerated dementia and kidney disease with long-term use.
Hiatal hernia — digestive anatomy illustration

Types of Hiatal Hernia

🔵 Type I — Sliding Hiatal Hernia (95%)

The gastroesophageal junction and a portion of the stomach slide in and out of the chest through the hiatus. The hernia appears and disappears with position changes and intra-abdominal pressure. The most common type — causes GERD, heartburn, regurgitation, and chest discomfort. Responds well to dietary and positional interventions.

🔴 Type II–IV — Paraesophageal / Rolling (5%)

The gastroesophageal junction remains in position, but part of the stomach rolls up beside the esophagus. Less likely to cause acid reflux but more dangerous — the herniated stomach portion can become trapped, twisted (volvulus), or strangulated. May require surgical repair. Symptoms: chest pain, difficulty swallowing, early satiety, vomiting.

20%
Of adults have a hiatal hernia
55–60%
Of adults over 50 have some herniation
60%+
Of hiatal hernia patients have coexisting SIBO
10–15
Years average PPI use in symptomatic patients
Symptom Profile

Signs & Symptoms of Hiatal Hernia

Symptoms are primarily driven by gastroesophageal reflux and impaired lower esophageal sphincter function.

🔥 GERD & Esophageal Symptoms

🔥

Heartburn (Pyrosis)

Burning sensation in the chest or throat caused by acid refluxing into the esophagus — which lacks the protective mucus lining of the stomach. Worsens after meals, when lying down, bending forward, or with increased abdominal pressure (coughing, straining). The most common symptom, occurring in 80% of cases.

🤮

Acid Regurgitation

Sour or bitter fluid — gastric acid mixed with partly digested food — rising into the mouth or throat. Often worsens at night when lying flat, causing the "wet burps," bad breath, and damage to tooth enamel that are characteristic of chronic GERD.

😮

Dysphagia (Difficulty Swallowing)

Food getting stuck in the throat or chest — caused by esophageal inflammation (esophagitis), strictures from chronic acid damage, or mechanical obstruction from the herniated tissue. Requires urgent evaluation, particularly if accompanied by weight loss.

🫁

Chronic Cough & Laryngitis

Acid microaspirations trigger airway irritation — causing a persistent dry cough (worse at night or in the morning), hoarseness, sore throat, and frequent throat clearing. Often misdiagnosed as allergies, asthma, or post-nasal drip when the actual driver is laryngopharyngeal reflux (LPR).

🧠 Upper GI & Systemic Symptoms

💨

Belching, Bloating & Gas

Excessive belching from swallowed air or fermentation; upper abdominal bloating from impaired gastric emptying. The herniated stomach segment may trap gas and create a sense of persistent upper abdominal fullness or pressure.

🫀

Chest Pain (Non-Cardiac)

Esophageal spasm triggered by acid exposure causes chest pain that is indistinguishable from cardiac pain — a common ER presentation. The pain may radiate to the jaw, arms, or back. Always rule out cardiac causes first. Once confirmed non-cardiac, it is manageable with dietary and supplemental interventions.

🤢

Nausea & Vomiting

Impaired gastric emptying from positional dysfunction of the stomach and vagal nerve irritation causes nausea — particularly in the morning or after large meals. In large paraesophageal hernias, vomiting can be severe and indicate a mechanical obstruction requiring urgent surgical attention.

🩸

Iron-Deficiency Anemia

Chronic irritation and micro-bleeding from the herniated gastric mucosa (Cameron erosions) causes slow, occult blood loss — leading to iron-deficiency anemia. Unexplained iron deficiency in a patient over 50 with reflux symptoms should prompt evaluation for hiatal hernia.

Diagnosis

How to Diagnose Hiatal Hernia & Its Complications

🔬 Primary Diagnostic Tests

🔭 Upper Endoscopy (EGD)

The most definitive diagnostic tool — directly visualizes the hernia, assesses esophageal damage (esophagitis, Barrett's esophagus — a precancerous change), identifies Cameron erosions, and rules out malignancy. Performed under light sedation. Recommended for all symptomatic patients, especially those over 45 or with alarm symptoms (dysphagia, weight loss, anemia).

☢️ Barium Swallow X-Ray

Patient swallows barium contrast while fluoroscopic X-rays capture real-time movement through the esophagus and stomach. Excellent for visualizing the hernia anatomy, the degree of herniation, and for evaluating paraesophageal hernias. Also detects esophageal motility disorders.

🧪 Esophageal pH Monitoring

A pH probe worn for 24–48 hours measures acid exposure time in the esophagus. Quantifies the frequency and duration of reflux episodes and correlates them with symptoms. The Bravo wireless pH capsule attaches to the esophageal wall for 48-hour wireless monitoring without a nasal catheter.

🩺 Functional & Nutritional Assessment

🧬 SIBO Breath Test

Hiatal hernia with chronic PPI use is a major risk factor for SIBO — acid suppression allows bacteria to colonize the small intestine. Over 60% of patients on long-term PPIs have SIBO. A lactulose or glucose breath test should be performed in all patients with bloating, gas, and non-responsive GERD symptoms.

🩸 Nutritional Deficiency Panel

Long-term acid suppression depletes: B12, magnesium, iron/ferritin, calcium, zinc. All patients on PPIs for more than 6 months should have these tested. Deficiencies explain many of the long-term complications of PPI therapy (bone loss, neuropathy, fatigue, immune dysfunction).

📏 Esophageal Manometry

Measures the strength and coordination of esophageal muscle contractions and LES pressure. Identifies if low LES resting pressure, esophageal dysmotility, or achalasia is contributing to reflux symptoms. Required before anti-reflux surgery to ensure normal esophageal peristalsis.

Treatment Comparison

Holistic vs. Conventional Treatment for Hiatal Hernia

🌿 HOLISTIC
💊 CONVENTIONAL
🌿

Holistic / Functional Approach

Dietary triggers, meal timing, positional strategies, DGL licorice, aloe vera, digestive enzymes, gut healing

Primary Strategy
Reduce intra-abdominal pressure, heal esophageal mucosa, restore LES tone, treat coexisting SIBO
Key Supplements
DGL licorice, Slippery elm, Aloe vera, Zinc carnosine, Digestive enzymes
Timeline
Significant symptom reduction within 2–4 weeks with dietary change; full mucosal healing in 3–6 months
Advantage
Addresses mucosal healing and LES function — not merely acid suppression; no drug depletion side effects
Full Holistic Protocol Includes
  • Eat smaller meals (4–5 small vs. 2–3 large) — reduces stomach volume and intra-abdominal pressure, decreasing herniation of stomach above the diaphragm
  • Nothing to eat 3+ hours before bed — gives stomach time to empty before lying down; prevents nocturnal acid exposure
  • Head-of-bed elevation (6–8 inches) using a wedge pillow — gravity reduces acid contact time with esophageal mucosa during sleep by 50%
  • DGL licorice (chewable tablets before meals) — stimulates mucus production, heals esophageal and gastric mucosa without raising BP
  • Slippery elm bark powder — creates a protective mucilage layer over the inflamed esophagus and stomach lining
  • Aloe vera juice (inner leaf fillet, 2–4 oz before meals) — anti-inflammatory, soothes the esophagus, reduces LES inflammation
  • Zinc carnosine — repairs the gastric mucosal barrier, reduces H. pylori adherence, and accelerates ulcer healing
  • Digestive enzymes with meals — support complete digestion, reducing fermentation and gas pressure that pushes against the LES
  • Weight management — each 5kg of excess abdominal weight increases intra-abdominal pressure and hernia severity
  • Address SIBO if present — SIBO-driven gas pressure is a major LES-destabilizing force in hiatal hernia
✅ Key insight: Contrary to popular belief, many GERD and hiatal hernia patients have LOW stomach acid (hypochlorhydria) — not too much. PPI use worsens this over time. A betaine HCl challenge test can reveal whether your acid is actually low, which requires a fundamentally different treatment approach.
Holistic Physical Techniques

Physically Relocating the Hernia: Self-Massage & Gravity Techniques

A sliding hiatal hernia — where the upper stomach periodically pushes up through the diaphragm opening — can often be mechanically encouraged back into its correct anatomical position using targeted manual pressure and gravity-assisted techniques. These approaches are used by specialized chiropractors and osteopaths, and can also be performed safely by the patient at home. They do not cure the underlying diaphragm weakness, but they relieve the acute herniation, reduce pressure on the LES, and provide immediate symptom relief.

⚠️ Important: These techniques are appropriate for sliding hiatal hernias confirmed by diagnosis. Do NOT attempt if you have a para-esophageal (type II/III/IV) hernia, recent abdominal surgery, active ulcers, or severe chest pain. If symptoms worsen during or after any technique, stop immediately and consult your physician. When in doubt, seek a qualified chiropractor or osteopath trained in visceral manipulation for your first session.

🙌 Technique 1: Stomach Self-Massage (Abdominal Release)

This soft-tissue technique uses downward manual pressure just below the xiphoid process (the cartilage tip at the base of the sternum) to gently encourage the herniated stomach fundus back below the diaphragm. Best performed first thing in the morning on an empty stomach, when the abdomen is most relaxed and stomach volume is minimal.

1
Position yourself correctly. Lie flat on your back on a firm surface (floor or firm bed) with knees slightly bent, feet flat, and abdomen relaxed. Place a small pillow under your knees if needed to release abdominal tension. Take 3–4 slow, deep diaphragmatic breaths to relax the abdominal wall before beginning.
2
Locate the xiphoid process. Find the soft cartilage tip at the very bottom of your sternum (breastbone), where the ribs meet in the center. Place the fingertips of both hands together just below this point — approximately 1–2 inches below the sternum, at the soft tissue of the upper abdomen (the epigastric area).
3
Apply gentle downward pressure. Using the flat pads of your fingers (not fingertips), press inward and downward — toward your feet — with gentle but firm pressure. You are aiming to contact the upper stomach through the abdominal wall. The pressure should feel like a 4–5 out of 10 — present but not painful. Never force or jab.
4
Slowly stroke downward. While maintaining firm contact, slowly drag your fingers downward from the epigastric area toward the navel — a stroke of 3–4 inches. Imagine you are gently pushing the top of the stomach away from the diaphragm and back into the abdomen. Repeat this downward stroke 10–15 times, releasing and repositioning between strokes.
5
Breathe with the technique. Inhale as you position your fingers; exhale fully as you apply the downward stroke — the abdominal wall naturally relaxes on exhalation, allowing deeper contact. The natural relaxation of the diaphragm on the out-breath creates a window in which the stomach is most free to descend. This is the optimal moment for the downward stroke.
6
Complete the session. After 10–15 strokes, rest for 1–2 minutes lying flat. Many patients notice immediate reduction in upper chest tightness, belching pressure, or the sensation of fullness high in the chest — signs that the stomach has descended. Perform once or twice daily, ideally before breakfast and before bed.

🏥 Professional Visceral Manipulation

Chiropractors and osteopaths trained in visceral manipulation (a specialized manual therapy technique developed by Jean-Pierre Barral, DO) can perform a more precise and effective version of the stomach relocation technique. A trained practitioner can:

  • Apply specifically targeted pressure to the gastroesophageal junction and stomach fundus, gently drawing the herniated tissue back below the diaphragm while simultaneously releasing the diaphragm's tension around the hiatus
  • Assess and release tension in the diaphragm muscle itself — a tight, hypertonic diaphragm actively pulls the stomach upward and is a primary driver of recurrent herniation. Diaphragm release significantly reduces recurrence rates
  • Address secondary restrictions in the liver, esophagus, and pericardium that can tether the stomach upward via fascial connections
  • Teach the patient proper self-care techniques and assess whether the anatomy has repositioned successfully through palpation

Search for practitioners certified in Barral Visceral Manipulation or osteopaths with specific abdominal/visceral technique training. Many patients report substantial and lasting symptom relief after 3–6 sessions combined with home self-massage and dietary management.

💧 Technique 2: The Water & Gravity Drop

This widely-used technique uses the weight and momentum of water in the stomach combined with a controlled gravity jolt to pull the stomach fundus downward through the diaphragmatic hiatus. It has been used by natural health practitioners for decades and many patients report immediate, dramatic relief from the sensation of pressure, tightness, and difficulty swallowing that accompanies an acute herniation.

1
Prepare on an empty stomach. Perform this technique first thing in the morning before eating or drinking anything else. An empty stomach is lighter and more mobile. Wait at least 3–4 hours after your last meal if doing this at any other time of day.
2
Drink 2 full glasses of warm water quickly. Use warm (not cold, not hot) water — approximately 400–500ml total. Drink it fairly quickly (within 30–60 seconds) rather than sipping slowly. The warmth relaxes the smooth muscle of the stomach and diaphragm; the volume fills and weights the stomach, pulling it downward by gravity. Cold water causes smooth muscle contraction, which is counterproductive.
3
Stand on your toes, arms raised. Immediately after drinking, stand upright and raise both arms above your head (or place hands on your shoulders and raise elbows). Rising onto your toes stretches the torso and creates traction in the upper abdominal cavity — momentarily widening the space between the diaphragm and stomach. This lengthening of the torso is essential before the drop.
4
Drop your heels sharply to the floor. From the tiptoe position, abruptly drop your heels down to flat-footed — landing with a firm, controlled thud. The sudden downward jolt sends a gravitational impulse through the water-weighted stomach, momentarily creating enough downward momentum to pull the herniated portion of the stomach back below the diaphragm. Repeat 5–10 times in quick succession.
5
Optional: step down from a chair. For a stronger gravitational impulse — particularly helpful when the heel drop alone is insufficient — stand on a low step or sturdy chair (6–10 inches high) and step down firmly with both feet, landing flat-footed with a controlled but confident impact. The increased drop distance creates greater gravitational force on the water-weighted stomach. Do this 3–5 times. Use a stable surface and hold a wall for balance.
6
Finish with deep diaphragmatic breathing. Immediately after the drops, take 5 slow, deep belly breaths — expanding the lower ribcage outward and downward. This activates the diaphragm rhythmically and helps seat the stomach in its lowered position. Many patients feel an audible gurgle or a palpable release of upper chest tightness — a sign the stomach has repositioned.
💡 Tip: For best results, combine both techniques in sequence: perform the self-massage first (5–10 minutes lying down), then stand up, drink the warm water, and immediately perform the heel drops / chair step. The massage softens and mobilizes the tissue; the water technique then uses gravity to complete the relocation.

📅 Frequency & Maintenance Protocol

🌅
Daily (morning routine): Water + gravity drop technique every morning before breakfast. Takes 3–5 minutes. This is the single most impactful time — the stomach is empty, the body is rested, and starting the day with the stomach in correct position prevents daytime symptoms from accumulating.
🌙
Evening (optional): Self-massage technique before bed, lying on your back. Helps prevent the stomach from being drawn upward during sleep — particularly important if you experience nighttime symptoms, regurgitation, or morning hoarseness.
🚨
Acute flares: Both techniques can be used during acute herniation episodes — sudden worsening of chest pressure, difficulty swallowing, or inability to belch. The water + drop technique is particularly fast-acting during acute episodes.
🏥
Professional sessions: 1 session every 2–4 weeks with a visceral manipulation practitioner during the active treatment phase (first 2–3 months), then monthly maintenance. Most patients achieve significant long-term improvement in 6–8 sessions when combined with consistent home practice and dietary management.

🔬 Why These Techniques Work: The Anatomy

🫁 The Diaphragmatic Hiatus

The esophagus passes through the diaphragm via an opening called the hiatus. In a hiatal hernia, the upper portion of the stomach (the fundus) slides upward through this opening, pulled by intra-abdominal pressure, a shortened esophagus, or diaphragm weakness. The hiatus is elastic — a herniated stomach can be encouraged back through it with the right mechanical inputs.

💧 Why Water Weight Helps

The stomach in a hernia state is partially above the diaphragm — essentially weightless relative to abdominal gravity. Filling it quickly with 400–500ml of warm water creates 400–500g of gravitational pull, plus the warmth relaxes both the stomach's smooth muscle and the diaphragm's crural fibers around the hiatus — creating a window in which the weighted stomach can descend freely.

⬇️ The Gravity Impulse

The heel drop / chair step creates a brief, high-amplitude gravitational force that exceeds normal hydrostatic pressure — generating enough downward momentum in the water-weighted stomach to overcome the slight resistance of the diaphragmatic hiatus and pull the herniated tissue back to its correct anatomical position below the diaphragm. The effect is immediate and often audibly confirmed by a stomach gurgle as contents settle.

Nutritional Strategy

Anti-Reflux Diet for Hiatal Hernia

Dietary management is the cornerstone of hiatal hernia treatment — both by reducing acid production and by controlling the mechanical pressure dynamics that allow the stomach to herniate.

✅ Soothing & Healing Foods:

🌿 Alkaline-Forming Foods

Bananas, melons, oatmeal, fennel, ginger, leafy greens, cauliflower, asparagus. These foods are either non-acidic or create an alkaline ash during digestion, reducing esophageal acid exposure. Particularly helpful as the dominant food group during flares.

🐟 Lean Proteins

Chicken breast, fish (baked/steamed), egg whites, turkey. Lean proteins stimulate less gastric acid production than fatty meats and don't relax the LES the way high-fat meals do. Steam, poach, or bake — avoid frying which adds LES-relaxing fat.

🫚 Bone Broth

Rich in glycine, proline, and gelatin — all of which directly support the repair of the esophageal and gastric mucosa. The gelatin forms a temporary protective coating on irritated tissues. Warm (not hot) bone broth before meals is a therapeutic pre-meal ritual for hiatal hernia healing.

❌ Trigger Foods to Eliminate:

☕ Coffee, Tea & Caffeine

Caffeine directly relaxes the lower esophageal sphincter — even in the absence of hiatal hernia. Combined with increased gastric acid stimulation, coffee is one of the most potent dietary GERD triggers. Both regular and decaf coffee cause LES relaxation via methylxanthines.

🍫 Chocolate, Peppermint & Spearmint

Three potent LES relaxants — avoid completely during active hernia management. Chocolate contains methylxanthines (like caffeine) and serotonin; both mint oils directly relax esophageal smooth muscle. The classic "healthy after-dinner mint" is counterproductive for hiatal hernia patients.

🍅 Acidic & Spicy Foods

Tomatoes, tomato sauce, citrus fruits, vinegar-based foods, hot spices (capsaicin). These directly increase esophageal acid exposure and irritate already inflamed mucosa. Eliminate tomatoes and citrus entirely during the healing phase — they can be cautiously reintroduced once mucosal repair is confirmed.

🧅 Onions, Garlic & High-Fat Foods

Raw onions and garlic are potent reflux triggers for many patients (cooked forms are better tolerated). High-fat meals delay gastric emptying for 4–6 hours — prolonging acid production and the window for reflux. Switch to low-fat cooking methods during active treatment.

Supplement Protocol

Key Supplements for Hiatal Hernia & GERD Relief

These supplements soothe inflamed mucosa, protect the esophagus from acid damage, restore LES tone, and address the underlying digestive dysfunction driving chronic reflux.

SupplementRole in Hiatal Hernia ManagementSuggested DoseTimingNotes
DGL Licorice (Deglycyrrhizinated)Stimulates mucus production in the esophageal and gastric lining — creating a thick protective barrier against acid damage. Accelerates the healing of esophageal erosions without suppressing acid (unlike PPIs). Also reduces H. pylori adhesion to the gastric mucosa and has mild anti-inflammatory effects on esophageal tissue. DGL form does not raise blood pressure.400–800mg chewable tablets, 2–3x/day20 minutes BEFORE meals and at bedtime — must be chewed for saliva to activate the mucosa-stimulating effectChewable form is essential — swallowed capsules do not stimulate esophageal mucosa. DGL is the safe form (glycyrrhizin removed). Whole licorice root raises BP — avoid for GERD use.
Slippery Elm BarkForms a thick, gel-like mucilage that coats and soothes the esophagus, stomach, and intestinal lining. The demulcent action creates a physical barrier between acid and the inflamed mucosa — providing immediate symptomatic relief while supporting mucosal regeneration. One of the oldest and most validated herbal remedies for GI inflammation.1–2 tsp powder mixed in warm water, 3x/dayBetween meals and before bedPowder form mixed in water creates the most effective mucilage. Capsule form is less effective. Safe for long-term use — also beneficial for IBD and leaky gut.
Aloe Vera Juice (Inner Leaf)Contains acemannan and anthraquinone compounds that reduce esophageal and gastric inflammation, inhibit gastric acid secretion, and accelerate mucosal healing. A 2015 randomized controlled trial showed aloe vera syrup was as effective as ranitidine and omeprazole for reducing GERD symptoms — without side effects.2–4 oz before meals (inner leaf fillet juice only)15–20 minutes before mealsInner leaf fillet ONLY — whole leaf contains aloin, a potent laxative. Choose decolorized, purified aloe vera juice.
Zinc Carnosine (PepZin GI)A chelated compound of zinc and L-carnosine that is uniquely stable in the stomach — releasing slowly over 2+ hours in direct contact with the gastric mucosa. Accelerates gastric ulcer healing, reduces H. pylori virulence, protects against NSAID-induced damage, and strengthens the mucus barrier. The most effective mucosal repair supplement for the stomach and lower esophagus.75mg (PepZin GI) 2x/day30 minutes before mealsWell-validated in Japanese clinical trials. Superior to zinc alone. Also improves gastric motility and reduces H. pylori colonization without antibiotics.
Digestive Enzymes (with meals)Incomplete protein and fat digestion leads to fermentation, excess gas production, and increased intra-abdominal pressure — all of which worsen LES pressure and hernia symptoms. Comprehensive digestive enzymes (including protease, lipase, amylase) ensure complete digestion in the stomach, preventing fermentation-driven gas buildup below the LES.1–2 capsules per mealAt the beginning of each mealAvoid formulas with betaine HCl initially if esophagitis is active — HCl irritates inflamed esophageal tissue. Reintroduce HCl cautiously after mucosal healing.
D-LimoneneA natural compound from citrus peel that adheres to the esophageal and gastric mucosa, neutralizes acid, and stimulates normal peristalsis and mucus production. Clinical trials show significant GERD symptom reduction with 1g every other day for 20 days. Acts as a natural "coating agent" and normalizes gastric emptying — reducing the window for reflux.1,000mg every other dayWith food (cycling protocol: 20 days on, then as needed)Despite coming from citrus, d-Limonene does not increase acidity — it neutralizes it. Paradoxical but well-validated. Bioavailable only when taken with a fat-containing meal.
Magnesium GlycinateMagnesium has mild prokinetic effects on the gut — stimulating gastric emptying and reducing the time food sits in the stomach fermenting. Reduces LES smooth muscle spasm. Magnesium depletion from PPI use is a major complication — repletion restores LES muscle function and prevents cardiac arrhythmia risk associated with hypomagnesemia.300–400mg elemental magnesium before bedBefore bedtimeGlycinate form has no laxative effect at this dose. If switching off PPIs, magnesium supplementation is essential from day one as rebound acid hypersecretion depletes magnesium further.
Vitamin B12 (Methylcobalamin)Gastric acid is essential for B12 absorption — it cleaves B12 from food proteins and activates intrinsic factor production. Long-term PPI use causes clinically significant B12 depletion in 30–40% of users, leading to fatigue, neuropathy, mood disturbance, and dementia risk. Sublingual B12 bypasses the need for gastric acid entirely.1,000–2,000mcg/day (sublingual)Morning, dissolve under tongueSublingual methylcobalamin is the only form that absorbs completely without stomach acid. Essential for all long-term PPI users — should be tested annually.
Next Steps

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