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Gastroesophageal reflux disease

What's new

The American Society for Gastrointestinal Endoscopy (ASGE) has published an updated guideline for the diagnosis and management of gastroesophageal reflux disease (GERD). Upper GI endoscopy is recommended for patients with GERD symptoms and alarm signs, as well as suggested for those with Barrett's esophagus risk factors and pediatric patients, even in the absence of alarm signs. Endoscopic evaluation is also suggested for certain patient groups, such as those with reflux symptoms after sleeve gastrectomy or peroral endoscopic myotomy (POEM), with postoperative interval screening offered for asymptomatic patients. Initial therapy includes weight loss, smoking cessation, elevation of the head of the bed, avoiding meals within 3 hours of bedtime, and proton pump inhibitors (PPIs), with optimization and de-escalation of PPIs for those on chronic therapy (>6 months). Testing for CYP2C19 polymorphism is suggested in patients with a suboptimal clinical response to PPIs to guide dosage and selection. .

Background

Overview

Definition
GERD is a disorder characterized by symptoms or signs caused by regurgitation of gastric contents into the esophagus, larynx, oral cavity, or lungs.
1
Pathophysiology
GERD is due to transient lower esophageal sphincter relaxations, reduced lower esophageal sphincter pressure, hiatal hernias, impaired esophageal clearance, and delayed gastric emptying.
2
Epidemiology
The estimated prevalence of GERD symptoms in the US ranges from 6% to 30%, with a weekly prevalence of symptoms approaching 20%.
3
Disease course
Reflux of gastric contents leads to damage of the esophagus, heartburn, bronchoconstriction, esophagitis, strictures, Barrett's esophagus, and esophageal cancer.
4
Prognosis and risk of recurrence
Barrett's esophagus occurs in about 10% of patients with chronic GERD.
5

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of gastroesophageal reflux disease are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2025), the American Society for Gastrointestinal Endoscopy (ASGE 2025), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES 2025), the American Gastroenterological Association (AGA 2024,2023,2012), the United European Gastroenterology (UEG/ESPEN ...
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Screening and diagnosis

Diagnostic criteria: as per ACG 2013 guidelines, establish a presumptive diagnosis of GERD in the setting of typical symptoms of heartburn and regurgitation.
B
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  • Differential diagnosis

Classification and risk stratification

Endoscopic classification
As per ACG 2013 guidelines:
Categorize the endoscopic appearance of erosive esophagitis according to the Los Angeles classification system.
B
Obtain further testing in patients with Los Angeles Grade A esophagitis to confirm the presence of GERD.
B
Los Angeles classification of esophagitis
Endoscopic findings
One or more mucosal break(s) ≤ 5 mm, not extending between the tops of two mucosal folds
One or more mucosal break(s) > 5 mm, not extending between the tops of two mucosal folds
One or more mucosal break(s) continuous between the tops of ≥ 2 mucosal folds involving < 75% of the esophageal circumference
One or more mucosal break(s) involving ≥ 75% of the esophageal circumference
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Diagnostic investigations

Barium esophagram: as per ACG 2022 guidelines, do not obtain barium swallow solely as a diagnostic test for GERD.
D
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  • Ambulatory esophageal reflux monitoring

  • Esophageal manometry

  • Screening for H. pylori infection

  • Nutritional assessment

  • Evaluation for gastroparesis

Diagnostic procedures

Upper gastrointestinal endoscopy, indications: as per ASGE 2025 guidelines, perform upper endoscopy in patients with GERD symptoms presenting with alarm symptoms, such as dysphagia, odynophagia, weight loss, gastrointestinal bleeding, persistent vomiting, or unexplained iron deficiency anemia.
B
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  • Upper gastrointestinal endoscopy (technical considerations)

Medical management

PPIs, initiation: as per ASGE 2025 guidelines, offer PPIs at the lowest possible dose for the shortest possible period of time in patients with symptomatic and confirmed GERD with predominant heartburn symptoms, while initiating discussion about long-term management options.
B
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  • PPIs (de-escalation)

  • PPIs (maintenance therapy)

  • PPIs (management of side effects)

  • Potassium-competitive acid blockers

  • Non-acid suppressive therapies

Nonpharmacologic interventions

Dietary modifications: as per ASGE 2025 guidelines, advise patients to avoid meals within 3 hours of bedtime.
B
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  • Weight loss

  • Smoking cessation

  • Sleep-related interventions

Therapeutic procedures

Transoral incisionless fundoplication
As per ACG 2022 guidelines:
Consider performing transoral incisionless fundoplication in patients with troublesome regurgitation or heartburn not wishing to undergo antireflux surgery and not having a severe esophagitis (Los Angeles grade C or D) or hiatal hernias > 2 cm.
C
Consider performing transoral incisionless fundoplication in patients with regurgitation as their primary PPI-refractory symptom and in patients with abnormal gastroesophageal reflux documented by objective testing.
C
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  • Medigus ultrasonic surgical endostapler

  • Stretta radiofrequency ablation

  • Magnetic sphincter augmentation

Perioperative care

Preoperative evaluation
As per ACG 2022 guidelines:
Obtain careful evaluation to ensure that GERD is present and causes the symptoms, to exclude achalasia (which can be associated with symptoms such as heartburn and regurgitation that can be confused with GERD) and conditions that might be contraindications to invasive treatment, such as absent contractility, before performing invasive therapy for GERD.
B
Obtain high-resolution manometry before antireflux surgery or endoscopic therapy to rule out achalasia and absent contractility. Obtain provocative testing to identify contractile reserve (such as multiple rapid swallows) in patients with ineffective esophageal motility.
B
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Surgical interventions

Indications for antireflux surgery: as per ASGE 2025 guidelines, consider evaluating patients with confirmed GERD and a small hiatal hernia (≤ 2 cm) with Hill grade I or II for transoral incisionless fundoplication as an alternative to chronic medical management if they meet any of the following criteria:
chronic GERD for at least 6 months
chronic PPI use (≥ 6 months) for GERD symptoms
refractory GERD
regurgitation-predominant GERD
preference to avoid long-term PPI use.
C
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  • Technical considerations for antireflux surgery

  • Bariatric surgery

Specific circumstances

Pregnant patients: as per ACG 2013 guidelines, recognize that PPIs are safe in pregnant patients, if clinically indicated.
B
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  • Pediatric patients (history and physical examination)

  • Pediatric patients (diagnostic imaging)

  • Pediatric patients (upper gastrointestinal endoscopy)

  • Pediatric patients (manometry)

  • Pediatric patients (pH monitoring)

  • Pediatric patients (biomarkers)

  • Pediatric patients (trial of transpyloric/jejunal feeding)

  • Pediatric patients (trial of PPIs)

  • Pediatric patients (dietary modifications)

  • Pediatric patients (transpyloric/jejunal feeding)

  • Pediatric patients (positioning therapy)

  • Pediatric patients (acid suppression therapy)

  • Pediatric patients (prokinetics)

  • Pediatric patients (probiotics)

  • Pediatric patients (alternative and complementary medicine)

  • Pediatric patients (parental/patient counseling)

  • Pediatric patients (assessment of treatment response)

  • Pediatric patients (indications for referral)

  • Pediatric patients (indications for antireflux surgery)

  • Pediatric patients (alternatives to fundoplication)

  • Preterm infants

  • Patients with peptic strictures

  • Patients with extraesophageal symptoms (evaluation)

  • Patients with extraesophageal symptoms (management)

  • Patients after sleeve gastrectomy

  • Patients after POEM

Follow-up and surveillance

Monitoring for Barrett's esophagus
As per ACG 2013 guidelines:
Perform repeat endoscopy in patients with severe erosive reflux disease after a course of antisecretory therapy, in order to exclude underlying Barrett's esophagus.
B
Consider screening for Barrett's esophagus in patients with GERD being at high risk based on epidemiologic profile.
C
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  • Management of refractory disease