Updated Guidelines Aim to Improve GERD Diagnosis and Treatment

The American Society for Gastrointestinal Endoscopy (ASGE) has released updated clinical guidelines for diagnosing and managing gastroesophageal reflux disease (GERD), outlining evidence-based recommendations for endoscopic evaluation and treatment, including for patients with prior sleeve gastrectomy or peroral endoscopic myotomy.1

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GERD, characterized by troublesome heartburn or regurgitation, affects about 18% to 28% of US adults, with slightly higher overall prevalence in women, and is increasingly common alongside rising obesity rates, leading to complications like erosive esophagitis, Barrett esophagus, and esophageal cancer.2,3 The new guidelines address key clinical questions on the role of upper endoscopy, quality standards for endoscopic evaluation, the effectiveness of lifestyle changes and medications, and emerging endoscopic therapies such as transoral incisionless fundoplication and radiofrequency treatment.1

“We recognize that clinical decision making is complex. Guidelines, therefore, are not a substitute for a clinician's judgment. Such judgments may, at times, seem contradictory to our guidance because of many factors that are impossible to fully consider by guideline developers. Any clinical decisions should be based on the clinician's experience, local expertise, resource availability, and patient values and preferences,” the ASGE wrote.

The ASGE Standards of Practice (SOP) Committee developed these clinical guidelines using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology to ensure a transparent, evidence-based approach.

The process began with the formulation of six clinical questions in the PICO format (Population, Intervention, Comparator, Outcomes), which were approved by the ASGE Governing Board. Systematic literature reviews and meta-analyses were conducted to inform each question, using databases such as Ovid MEDLINE, Embase, and the Cochrane Library.

Studies were screened and selected based on strict inclusion criteria, focusing on randomized controlled trials, observational studies, and existing systematic reviews. Literature relevant to adult and pediatric populations was included, while outdated therapies and nonclinical trials were excluded. Data extraction was performed by independent reviewers, and meta-analyses were conducted using standard statistical models (primarily random effects models) to account for heterogeneity.

The quality of individual studies was assessed using tools like ROB, the Qumseya scale, and AMSTAR-2, depending on study design. GRADE methodologists then created evidence profiles by evaluating factors such as methodological limitations, consistency, and publication bias. Certainty in evidence was rated from very low to high.

A guideline development panel reviewed the evidence and discussed each recommendation, considering clinical benefits and harms, patient values, costs, feasibility, and equity. Final recommendations were voted on and approved by a simple majority, with strong recommendations phrased as “we recommend” and conditional ones as “we suggest.”

The American Society for Gastrointestinal Endoscopy (ASGE) made evidence-based recommendations regarding the use of upper endoscopy in patients with GERD and related conditions.

For patients presenting with GERD symptoms, the ASGE recommends upper endoscopy, particularly in those exhibiting alarm symptoms such as dysphagia, weight loss, or gastrointestinal bleeding. This recommendation extends to individuals with multiple risk factors for Barrett esophagus and those with a history of sleeve gastrectomy (SG) or peroral endoscopic myotomy (POEM). In symptomatic patients post-SG or POEM, endoscopic evaluation is suggested. For asymptomatic patients following SG, the ASGE suggests initiating endoscopic screening for Barrett esophagus three years after the procedure, with subsequent screenings every five years. If Barrett esophagus is detected, follow-up should adhere to existing surveillance guidelines. Given the high incidence of post-POEM GERD, periodic endoscopic evaluations may be considered even in asymptomatic individuals.

In terms of procedural quality, the ASGE emphasizes meticulous endoscopic evaluation, reporting, and photo-documentation of objective GERD findings, including erosive esophagitis (graded using the Los Angeles classification), Barrett esophagus (using the Prague classification), and peptic strictures. Assessment of the gastroesophageal junction's landmarks and integrity—such as hiatal hernia dimensions (via Hill or American Foregut Society grading), the Z-line, diaphragmatic impression, and gastric folds—is crucial for accurate diagnosis and management.

Lifestyle modifications are strongly recommended for GERD management. These include weight loss for overweight or obese patients, smoking cessation, elevating the head of the bed, and avoiding meals within three hours of bedtime. For medical therapy, proton pump inhibitors (PPIs) are advised at the lowest effective dose for the shortest duration necessary. In cases of suboptimal response to PPIs, testing for CYP2C19 polymorphisms and adjusting PPI dosage or selection accordingly is suggested.

Regarding endoscopic interventions, the ASGE suggests evaluating transoral incisionless fundoplication (TIF) as an alternative to long-term medical therapy for patients with confirmed GERD, small hiatal hernias (≤ 2 cm), and Hill grade 1 or 2 valves, especially in those with chronic or refractory GERD, regurgitation-predominant symptoms, or a preference to avoid prolonged proton pump inhibitor use.

For patients with larger hiatal hernias (> 2 cm) and Hill grade III or IV valves, combined hiatal hernia repair with TIF is suggested, following a multidisciplinary review. Additionally, for patients with confirmed GERD, small hiatal hernias (< 2 cm), and Hill grade 1 or 2 valves, radiofrequency energy treatment (Stretta) may be considered when other alternatives are unavailable or infeasible.

The guidelines also highlight the need for further research, particularly concerning the increasing prevalence of refractory GERD in pediatric populations, where anatomical or neurological conditions may limit the efficacy of medical therapy and the feasibility of surgical interventions. Short-term follow-up studies have demonstrated symptom improvement with minimal to moderate adverse events. However, comparative trials against medical therapy, TIF 2.0, and surgical fundoplication are necessary to establish the positioning of these interventions within the GERD treatment paradigm.

References

1. Desai M, Ruan W, Thosani NC, et al. American Society for Gastrointestinal Endoscopy guideline on the diagnosis and management of GERD: summary and recommendations. Gastrointest Endosc. 2025;101(2):267-284. doi:10.1016/j.gie.2024.10.008

2. Epidemiology, causes, and management of gastro-esophageal reflux disease: a systematic review. Cureus. 2023;15(10):e47420. doi:10.7759/cureus.47420

3. Definition & facts for GER & GERD. National Institute of Diabetes and Digestive and Kidney Diseases. NIH. Accessed May 6, 2025. https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/definition-facts