Gastroesophageal reflux disease (GERD) is a condition commonly encountered by health care clinicians. Patients often present with complaints of heartburn and regurgitation. Proton pump inhibitors (PPIs) are the main medical therapy for GERD. Recently, there have been questions regarding the safety of long-term PPI use and concerns surrounding potential overprescribing. Additionally, advances in treatment have added newer surgical and endoscopic options for patients with GERD.
In this side-by-side comparison, we look at the latest clinical practice guidelines from the American College of Gastroenterology (ACG) and the American Society for Gastrointestinal Endoscopy (ASGE) on the diagnosis and management of GERD. The recommendations made by these societies are meant to guide clinical practice, taking into consideration the unique desires and needs of individual patients.
Guidelines for Comparison
| Item | ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease | American Society for Gastrointestinal Endoscopy Guideline on the Diagnosis and Management of GERD: Summary and Recommendations |
|---|---|---|
| Authoring Organization | The American College of Gastroenterology (ACG) | The American Society for Gastrointestinal Endoscopy (ASGE) |
| Publication Date | 2021 | 2024 |
| Graded Recommendations | Yes | Yes |
| Uses GRADE | Yes | Yes |
| Links | Summary / Full Text | Summary / Full Text |
Key Takeaways
Endoscopic Evaluation for GERD:
- Both societies agree that endoscopy should be performed to evaluate patients with alarm symptoms and risk factors for Barrett’s esophagus (BE).
- The ACG also recommends endoscopy for patients with chest pain (not heartburn) who have had cardiac etiology ruled out.
- ASGE goes on to make recommendations for endoscopic evaluation of pediatric patients and patients who have had a sleeve gastrectomy (SE) and peroral endoscopic myotomy (POEM).
- Recommendations on performing comprehensive and uniform endoscopic evaluations are also included in the ASGE guideline.
Management of GERD:
- Lifestyle Modifications
- Both societies agree with recommending weight loss for patients who are overweight or obese, smoking cessation, avoiding meals before bedtime, and elevating the head of bed to manage GERD symptoms.
- The ACG makes an additional recommendation to avoid trigger foods.
- Medication
- Both societies prefer PPI treatment over histamine-2-receptor antagonists, and recommend giving the lowest effective dose for the shortest period of time.
- The ACG gives a little more detail on PPI therapy, recommending a trial for 8 weeks and taking the PPI 30 to 60 minutes before meals.
- ASGE suggests patients with suboptimal clinical response to PPI therapy be tested for CYP2C19 polymorphism and dose adjustments be made if needed.
- The ACG recommends maintenance PPI therapy indefinitely or antireflux surgery for patients with LA grade C or D esophagitis. This was not addressed in the ASGE guideline.
- Also not addressed by ASGE are an option for intermittent PPI therapy for heartburn symptom control in patients with non-erosive reflux disease (NERD) and recommendations against the use of baclofen, prokinetics, and sucralfate (except during pregnancy) for GERD.
- Surgical/Endoscopic Treatments
- Both societies suggest evaluation for transoral incisionless fundoplication (TIF) for patients with refractory GERD who do not have a large hiatal hernia.
- The ASGE gives more detailed information about patient selection for surgery (hiatal hernia repair and TIF) compared to the ACG.
- The ACG recommends considering magnetic sphincter augmentation (MSA) or Roux-en-Y gastric bypass (RYGB) for certain patients with GERD. ASGE does not address these procedures.
- According to the ASGE radiofrequency energy to the lower esophageal sphincter can be considered when other alternatives (endoscopic/surgical fundoplication) are not available or feasible, while the ACG states that insufficient evidence exists to recommend the use of radiofrequency energy for GERD.
Other:
- The ACG guideline includes recommendations for patients with extraesophageal symptoms and refractory GERD which were not reviewed in this article.
Comparison of Recommendations
| Recommendation Type | ACG | ASGE |
|---|---|---|
| Evaluation | We recommend endoscopy as the first test for evaluation of patients presenting with dysphagia or other alarm symptoms (weight loss and GI bleeding) and for patients with multiple risk factors for Barrett's esophagus. We recommend diagnostic endoscopy, ideally after PPIs are stopped for 2–4 weeks, in patients whose classic GERD symptoms do not respond adequately to an 8-week empiric trial of PPIs or whose symptoms return when PPIs are discontinued. In patients who have chest pain without heartburn and who have had adequate evaluation to exclude heart disease, objective testing for GERD (endoscopy and/or reflux monitoring) is recommended. | In patients with GERD symptoms, the ASGE recommends upper endoscopy in those with: Alarm symptoms (dysphagia, odynophagia, weight loss, GI bleeding, persistent vomiting, or unexplained iron deficiency anemia). In patients with GERD symptoms but no alarm symptoms, the ASGE suggests endoscopic evaluation in those with: • Barrett's esophagitis (BE) risk factors (family history of BE or esophageal adenocarcinoma; GERD plus another risk factor [≥50 years, male sex, white race, smoking, or obesity]). • Infants and children with suggestive symptoms (poor weight gain, unexplained anemia, concern for GI bleeding, recurrent pneumonia, regurgitation and/or vomiting). |
| Not Addressed. | In patients who had sleeve gastrectomy (SG) and with reflux symptoms, the ASGE suggests endoscopic evaluation. In patients who had SG and are asymptomatic, the ASGE suggests endoscopic screening for 3 years after SG and then every 5 years. If BE is detected in this population, the ASGE recommends follow-up per existing BE surveillance guidelines. | |
| Not Addressed. | In patients who had peroral endoscopic myotomy (POEM) and have symptomatic GERD, the ASGE suggests endoscopic evaluation. | |
| Not Addressed. | In patients undergoing endoscopic evaluation for GERD symptoms, the ASGE recommends careful endoscopic evaluation, reporting, and photo-documentation of the following to improve patient care and outcomes: • Objective GERD findings, when present: • Erosive esophagitis (using the Los Angeles grading system) • BE (using the Prague classification) • Peptic stricture • Gastroesophageal junction landmarks and integrity: • Hiatal hernia dimensions using Hill grading or American Foregut Society grading in forward view and retroflexion • Location of top of gastric folds, Z line, diaphragmatic impression • Existing fundoplication description (if present). | |
| We do not recommend the use of a barium swallow solely as a diagnostic test for GERD. | Not Addressed. | |
| In patients for whom the diagnosis of GERD is suspected but not clear, and endoscopy shows no objective evidence of GERD, we recommend reflux monitoring be performed off therapy to establish the diagnosis. | Addressed in algorithm which agrees with ambulatory acid reflux monitoring off PPI for patients with no objective endoscopic signs of GERD. | |
| We recommend against performing reflux monitoring off therapy solely as a diagnostic test for GERD in patients known to have endoscopic evidence of Los Angeles (LA) grade C or D reflux esophagitis or in patients with long-segment Barrett's esophagus. | Not Addressed. | |
| Management | Lifestyle Modifications: We recommend weight loss in overweight and obese patients for improvement of GERD symptoms. We suggest avoiding meals within 2–3 hours of bedtime. We suggest avoidance of tobacco products/smoking in patients with GERD symptoms. We suggest avoidance of “trigger foods” for GERD symptom control. We suggest elevating the head of bed for nighttime GERD symptoms. | In patients with GERD symptoms, the ASGE recommends lifestyle modifications: • Weight loss for patients who are overweight or obese • Smoking cessation • Elevating the head of the bed • Avoiding meals within 3 hours of bedtime. |
| For patients with classic GERD symptoms of heartburn and regurgitation who have no alarm symptoms, we recommend an 8-week trial of empiric PPIs once daily before a meal. We recommend attempting to discontinue the PPIs in patients whose classic GERD symptoms respond to an 8-week empiric trial of PPIs. For patients with GERD who do not have erosive esophagitis (EE) or Barrett's esophagus, and whose symptoms have resolved with PPI therapy, an attempt should be made to discontinue PPIs or to switch to on-demand therapy in which PPIs are taken only when symptoms occur and discontinued when they are relieved. For patients with GERD who require maintenance therapy with PPIs, the PPIs should be administered in the lowest dose that effectively controls GERD symptoms and maintains healing of reflux esophagitis. | In patients with symptomatic and confirmed GERD with predominant heartburn symptoms, the ASGE recommends medical management with PPIs at the lowest possible dose for the shortest possible period of time while initiating discussion about long-term management options. | |
| Not Addressed. | In patients with suboptimal clinical response to PPI therapy, the ASGE suggests testing CYP2C19 polymorphism and adjusting PPI dosage and/or selection accordingly. | |
| We recommend treatment with PPIs over treatment with histamine-2-receptor antagonists (H2RA) for healing EE. | No specific recommendation made, however according to supporting text ASGE is in agreement. | |
| We recommend treatment with PPIs over H2RA for maintenance of healing from EE. | No specific recommendation made, however according to supporting text ASGE is in agreement. | |
| We recommend PPI administration 30–60 minutes before a meal rather than at bedtime for GERD symptom control. | Not Addressed. | |
| We recommend against routine addition of medical therapies in PPI nonresponders. | Not Addressed. | |
| We recommend maintenance PPI therapy indefinitely or antireflux surgery for patients with LA grade C or D esophagitis. | Not Addressed. | |
| We do not recommend baclofen in the absence of objective evidence of GERD. | Not Addressed. | |
| We recommend against treatment with a prokinetic agent of any kind for GERD therapy unless there is objective evidence of gastroparesis. | Not Addressed. | |
| We do not recommend sucralfate for GERD therapy except during pregnancy. | Not Addressed. | |
| We suggest on-demand or intermittent PPI therapy for heartburn symptom control in patients with non-erosive reflux disease (NERD). | Not Addressed. | |
| Surgical and Endoscopic Treatment Options | For patients who have regurgitation as their primary PPI-refractory symptom and who have had abnormal gastroesophageal reflux documented by objective testing, we suggest consideration of antireflux surgery or TIF. We suggest consideration of TIF for patients with troublesome regurgitation or heartburn who do not wish to undergo antireflux surgery and who do not have severe reflux esophagitis (LA grade C or D) or hiatal hernias >2 cm. | In patients with confirmed GERD and a small hiatal hernia (≤2 cm) and Hill grade 1 or 2 who meet any of the following criteria, the ASGE suggests evaluation for TIF as an alternative to chronic medical management: Chronic GERD (≥6 months) Chronic PPI use (≥6 months) for management for GERD symptoms Refractory GERD Regurgitation-predominant GERD Patient preference for avoidance of long-term PPI use. |
| We recommend antireflux surgery performed by an experienced surgeon as an option for long-term treatment of patients with objective evidence of GERD, especially those who have severe reflux esophagitis (LA grade C or D), large hiatal hernias, and/or persistent, troublesome GERD symptoms. | In patients with confirmed GERD and a large hiatal hernia (>2 cm) and Hill grade III or IV, the ASGE suggests evaluation for combined hiatal hernia repair and TIF (cTIF) in a multidisciplinary review. | |
| We recommend consideration of magnetic sphincter augmentation (MSA) as an alternative to laparoscopic fundoplication for patients with regurgitation who fail medical management. | Not Addressed. | |
| We suggest consideration of Roux-en-Y gastric bypass (RYGB) as an option to treat GERD in obese patients who are candidates for this procedure and who are willing to accept its risks and requirements for lifestyle alterations. | Not Addressed. | |
| Because data on the efficacy of radiofrequency energy (Stretta) as an antireflux procedure is inconsistent and highly variable, we cannot recommend its use as an alternative to medical or surgical antireflux therapies. | In patients with confirmed GERD, a small hiatal hernia (<2 cm), and Hill grade I or II, radiofrequency energy to the lower esophageal sphincter can be considered when other alternatives (endoscopic/surgical fundoplication) are not available or feasible. |
This concludes our side-by-side guideline comparison on the diagnosis and management of GERD.
Sign up for alerts to stay informed on the latest published guidelines and articles.
Copyright ® 2025 Guideline Central, all rights reserved.