ASGE updates guidance on diagnosing and managing GERD
About one-third of U.S. adults are affected by the condition.
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01/22/2026
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by Doug Brunk
The American Society for Gastrointestinal Endoscopy (ASGE) has released an updated clinical practice guideline that reshapes how clinicians should diagnose and manage gastroesophageal reflux disease (GERD), a condition that affects roughly one in three adults in the United States. The guideline, published in Gastrointestinal Endoscopy, updates the society’s 2014 recommendations and reflects advances in endoscopic techniques, growing concerns about long-term medication use, and emerging patient populations at higher risk for complications.
“Important advances have been made in the endoscopic management of GERD, which were not available a few years ago,” one of the study authors, Bashar J. Qumseya, MD, MPH, FASGE, ASGE Standards of Practice Committee Chair and a gastroenterologist at the University of Florida, Division of Gastroenterology, Hepatology & Nutrition, told GI & Hepatology News. “Procedures like transoral incisionless fundoplication are changing the way in which gastroenterologists think about and treat GERD. There is also increasing awareness regarding new risk factors for GERD."
One of the most important messages in the new guideline is a more targeted approach to upper endoscopy. The ASGE continues to emphasize that most patients with typical GERD symptoms do not need an endoscopy right away and can be managed initially with medical therapy.
However, endoscopy is strongly recommended for patients with alarm symptoms such as difficulty swallowing, unexplained weight loss, gastrointestinal bleeding, persistent vomiting, or iron deficiency anemia. The guideline also calls for greater use of endoscopy in patients with multiple risk factors for Barrett’s esophagus, even if symptoms are mild.
A notable change is the expanded focus on patients who develop reflux after certain procedures. The ASGE now suggests routine endoscopic screening for Barrett’s esophagus in patients who have undergone sleeve gastrectomy, starting three years after surgery and repeating every five years, even if they do not have reflux symptoms.
This recommendation reflects growing evidence that this group faces a higher risk of esophagitis and Barrett’s esophagus over time. Patients with reflux symptoms after peroral endoscopic myotomy should also be evaluated endoscopically, given the high rates of post-procedure GERD.
Another key theme is careful, standardized documentation during endoscopy. The guideline urges endoscopists to consistently record objective signs of GERD, such as erosive esophagitis and Barrett’s esophagus, and to clearly describe gastroesophageal junction anatomy, including hiatal hernia size and flap valve integrity. According to the authors, better documentation can reduce repeat procedures, improve treatment decisions, and support the growing role of endoscopic antireflux therapies.
The guideline also reinforces a balanced approach to treatment. Lifestyle changes such as weight loss, smoking cessation, avoiding late meals, and elevating the head of the bed are recommended for all patients with GERD symptoms. Proton pump inhibitors remain the cornerstone of medical therapy, but the ASGE recommends using the lowest effective dose for the shortest necessary duration, along with regular reassessment. Importantly, the guideline acknowledges patient concerns about long-term PPI use and encourages shared decision-making. In patients with a suboptimal clinical response to PPI therapy, the guideline recommends considering CYP2C19 polymorphism testing and adjusting the PPI dosage accordingly.
For patients with confirmed GERD who wish to avoid chronic medication, the guideline highlights endoscopic options. Transoral incisionless fundoplication may be considered for patients with small hiatal hernias and well-defined anatomy, while combined surgical and endoscopic approaches may be appropriate for those with larger hernias. Although the quality of evidence varies, the ASGE views these therapies as reasonable alternatives for carefully chosen patients.
“Giving patients proton pump inhibitors forever is no longer an-evidence based management approach to patients with GERD,” Dr. Qumseya concluded. “Careful evaluation of patients’ symptoms, endoscopic findings, and genetic testing should be incorporated to offer the best approach that is tailed to each specific patient.”
Dr. Qumseya disclosed that he serves as a consultant for Medtronic, Inc., and Assertio Management, LLC. He has also received food and beverage compensation from Medtronic, Inc., Fujifilm Healthcare Americas Corporation, and Boston Scientific Corporation, as well as speaker fees from Castle Biosciences. Several coauthors reported additional disclosures.
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The guidelines emphasize four-hour gastric emptying studies over two-hour testing. How do you see this affecting diagnostic workflows in practice?
Dr. Staller: Moving to a four-hour solid-meal scintigraphy will actually simplify decision-making. The two-hour reads miss a meaningful proportion of delayed emptying; standardizing on four hours reduces false negatives and the “maybe gastroparesis” purgatory that leads to repeat testing. Practically, it means closer coordination with nuclear medicine (longer slots, consistent standardized meal), updating order sets to default to a four-hour protocol, and educating front-line teams so patients arrive appropriately prepped. The payoff is fewer equivocal studies and more confident treatment plans.
Metoclopramide and erythromycin are the only agents conditionally recommended for initial therapy. How does this align with what is being currently prescribed?
Dr. Staller: This largely mirrors real-world practice. Metoclopramide remains the only FDA-approved prokinetic for gastroparesis, and short “pulsed” erythromycin courses are familiar to many of us—recognizing tachyphylaxis limits durability. Our recommendation is “conditional” because the underlying evidence is modest and patient responses are heterogeneous, but it formalizes what many clinicians already do: start with metoclopramide (lowest effective dose, limited duration, counsel on neurologic adverse effects) and reserve erythromycin for targeted use (exacerbations, bridging).
Several agents, including domperidone and prucalopride, received recommendations against first-line use. How will that influence discussions with patients who ask about these therapies?
Dr. Staller: Two points I share with patients: evidence and access/safety. For domperidone, the data quality is mixed, and US access is through an FDA IND mechanism; you’re committing patients to EKG monitoring and a non-trivial administrative lift. For prucalopride, the gastroparesis-specific evidence isn’t strong enough yet to justify first-line use. So, our stance is not “never,” it’s just “not first.” If someone fails or cannot tolerate initial therapy, we can revisit these options through shared decision-making, setting expectations about benefit, monitoring, and off-label use. The guideline language helps clinicians have a transparent, evidence-based conversation at the first visit.
The guidelines suggest reserving procedures like G-POEM and gastric electrical stimulation for refractory cases. In your practice, how do you decide when a patient is “refractory” to medical therapy?
Dr. Staller: I define “refractory” with three anchors.
1. Adequate trials of foundational care: dietary optimization and glycemic control; an antiemetic; and at least one prokinetic at appropriate dose/duration (with intolerance documented if stopped early).
2. Persistent, function-limiting symptoms: ongoing nausea/vomiting, weight loss, dehydration, ER visits/hospitalizations, or malnutrition despite the above—ideally tracked with a validated instrument (e.g., GCSI) plus nutritional metrics.
3. Objective correlation: delayed emptying on a standardized 4-hour solid-meal study that aligns with the clinical picture (and medications that slow emptying addressed).
At that point, referral to a center with procedural expertise for G-POEM or consideration of gastric electrical stimulation becomes appropriate, with multidisciplinary evaluation (GI, nutrition, psychology, and, when needed, surgery).
What role do you see dietary modification and glycemic control playing alongside pharmacologic therapy in light of these recommendations?
Dr. Staller: They’re the bedrock. A small-particle, lower-fat, calorie-dense diet—often leaning on nutrient-rich liquids—can meaningfully reduce symptom burden. Partnering with dietitians early pays dividends. For diabetes, tighter glycemic control can improve gastric emptying and symptoms; I explicitly review medications that can slow emptying (e.g., opioids; consider timing/necessity of GLP-1 receptor agonists) and encourage continuous glucose monitor-informed adjustments. Pharmacotherapy sits on top of those pillars; without them, medications will likely underperform.
The guideline notes “considerable unmet need” in gastroparesis treatment. Where do you think future therapies or research are most urgently needed?
Dr. Staller: I see three major areas.
1. Truly durable prokinetics: agents that improve emptying and symptoms over months, with better safety than legacy options (e.g., next-gen motilin/ghrelin agonists, better-studied 5-HT4 strategies).
2. Endotyping and biomarkers: we need to stop treating all gastroparesis as one disease. Clinical, physiologic, and microbiome/omic signatures that predict who benefits from which therapy (drug vs G-POEM vs GES) would transform care.
3. Patient-centered trials: larger, longer RCTs that prioritize validated symptom and quality-of-life outcomes, include nutritional endpoints, and reflect real-world medication confounders.
Our guideline intentionally highlights these gaps to hopefully catalyze better trials and smarter referral pathways.
Dr. Staller is with the Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston.