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. 2024 Dec 18;10(2):81-137.
doi: 10.1016/j.vgie.2024.10.001. eCollection 2025 Feb.

American Society for Gastrointestinal Endoscopy guideline on the diagnosis and management of GERD: methodology and review of evidence

ASGE Standards of Practice Committee; Madhav Desai  1 , Wenly Ruan  2 , Nirav C Thosani  1 , Manuel Amaris  3 , J Stephen Scott  4 , Ahmed Saeed  5 , Barham Abu Dayyeh  6 , Marcia Irene Canto  7 , Wasif Abidi  8 , Omeed Alipour  9 , Stuart K Amateau  10 , Natalie Cosgrove  11 , Sherif E Elhanafi  12 , Nauzer Forbes  13 , Divyanshoo R Kohli  14 , Richard S Kwon  15 , Larissa L Fujii-Lau  16 , Jorge D Machicado  15 , Neil B Marya  17 , Saowanee Ngamruengphong  7 , Swati Pawa  18 , Sunil G Sheth  19 , Nikhil R Thiruvengadam  20 , Bashar J Qumseya  3 ; ASGE Standards of Practice Committee Chair
Affiliations

American Society for Gastrointestinal Endoscopy guideline on the diagnosis and management of GERD: methodology and review of evidence

ASGE Standards of Practice Committee et al. VideoGIE. .

Abstract

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for strategies to diagnose and manage GERD. This document was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework and serves as an update to the prior ASGE guideline on the role of endoscopy in the management of GERD (2014). The updated guideline addresses the indications for endoscopy in patients with GERD, including patients who have undergone sleeve gastrectomy (SG) and peroral endoscopic myotomy (POEM). It also discusses endoscopic evaluation of gastroesophageal junctional integrity comprehensively and uniformly. Important, this guideline discusses management strategies for GERD including lifestyle interventions, proton pump inhibitors (PPIs), and endoscopic antireflux therapy including transoral incisionless fundoplication (TIF), radiofrequency energy, and TIF combined with hiatal hernia repair (cTIF). The ASGE recommends upper endoscopy for the evaluation of GERD in patients with alarm symptoms. The ASGE suggests upper endoscopy for symptomatic patients with a history of SG and POEM. The ASGE recommends careful endoscopic evaluation, reporting, and photo-documentation of objective GERD findings and gastroesophageal junction landmarks and integrity to improve patient care and outcomes. In patients with GERD symptoms, the ASGE recommends lifestyle modifications. In patients with symptomatic and confirmed GERD with predominant heartburn symptoms, the ASGE recommends medical management including PPIs at the lowest dose for the shortest duration while initiating discussion about long-term management options. In patients with confirmed GERD with small hiatal hernia (≤2 cm) and Hill grade I or II flap valve who meet specific criteria, the ASGE suggests evaluation for TIF as an alternative to long-term medical management. In patients with confirmed GERD with a large hiatal hernia (>2 cm) and Hill grade 3 or 4 flap valve, the ASGE suggests evaluation for combined endoscopic-surgical TIF (cTIF) in a multidisciplinary review. This document clearly outlines the methodology, analysis, and decision used to reach the final recommendations and represents the official ASGE recommendations on the above topics.

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Conflict of interest statement

N. C. Thosani is a consultant for and has received travel compensation and food and beverage from PENTAX of America, Inc, and Boston Scientific Corporation; is a speaker for and has received travel compensation and food and beverage from AbbVie Inc, and is a consultant for Ambu Inc. A. Saeed is a consultant for Endogastric Solutions, Medtronic, Boston Scientific Corporation, and Olympus. B. Abu Dayyeh is a consultant for Endogenex, Endo-TAGSS, Metamodix, and BFKW; is a consultant for and receives grant or research support from USGI, Apollo Endosurgery, Spatz Medical, Aspire Bariatrics, and Boston Scientific; has speaker roles with Olympus, Johnson and Johnson; is a speaker for and receives grant or research support from Medtronic and Endogastric Solutions; and receives grant support from ERBE Medical. M.I. Canto is a principal investigator on a research grant study with The Johns Hopkins University sponsored by Endogastric Solutions; is a consultant and on the scientific advisory board for Cernostics; has a research grant and clinical trial through Pentax Medical Corporation; was a consultant for ClearNote Health and Cernostics; and receives royalties from UpToDate. W. Abidi is a consultant for and has received food and beverage from Ambu Inc, Apollo Endosurgery US Inc, CONMED Corporation; has received research support from GI Dynamics; and has received food and beverage from Olympus America Inc, AbbVie Inc, Boston Scientific Corporation, RedHill Biopharma Inc, and Salix Pharmaceuticals. S.K. Amateau is a consultant for and has received travel compensation and food and beverage from Boston Scientific Corporation; is a consultant and on the advisory board for Merit Medical; is a consultant and has received food and beverage from Olympus Corporation of the Americas; is a consultant for MTEndoscopy, US Endoscopy, and Heraeus Medical Components, LLC; and is a consultant and has received food and beverage from Cook Medical LLC. N. Cosgrove is a consultant for Olympus Corporation of the Americas; is a consultant and has received food and beverage from Boston Scientific Corporation; and has received food and beverage from Ambu Inc S.E. Elhanafi has received food and beverage from Medtronic, Inc, Nestle HealthCare Nutrition Inc, Ambu Inc, Salix Pharmaceuticals, Takeda Pharmaceuticals U.S.A., Inc, and Merit Medical Systems Inc. N. Forbes has been a consultant for Boston Scientific Corporation and PENTAX of America, Inc; has been on the speaker bureau for PENTAX of America, Inc, and Boston Scientific Corporation; and has received research support from PENTAX of America, Inc D.R. Kohli has been a consultant for and has received a research grant from Olympus Corporation of the Americas. L.L. Fujii-Lau is a consultant for Boston Scientific Corporation and has received food and beverage from Pfizer Inc and AbbVie Inc. J.D. Machicado is a consultant for and has received food and beverage from Mauna Kea Technologies, Inc; and has received food and beverage from Boston Scientific Corporation. N.B. Marya is a consultant for and has received food and beverage from Boston Scientific Corporation; and has received food and beverage from Apollo Endosurgery US Inc S. Ngamruengphong is a consultant for Boston Scientific Corporation, Olympus, and Neptune Medical; and has received food and beverage from Medtronic, Inc, Boston Scientific Corporation, PENTAX of America, Inc, and Ambu Inc S. Pawa is a consultant for Boston Scientific Corporation. N.R. Thiruvengadam has received a grant from Boston Scientific Corporation. B.J. Qumseya is a consultant for and has received food and beverage from Medtronic, Inc; is a consultant for Assertio Management, LLC; is a speaker for Castle Biosciences; and has received food and beverage from FUJIFILM Healthcare Americas Corporation and Boston Scientific Corporation. The other authors disclosed no financial relationships.

Figures

Figure 1
Figure 1
PRISMA diagram showing the studies included in the systematic review evaluating endoscopic therapies TIF 2.0, radiofrequency energy (Stretta), and novel and emerging endoscopic therapies in adult patients with GERD. TIF 2.0, Transoral incisionless fundoplication 2.0 (Esophyx 2.0); RCT, randomized controlled trial.
Figure 2
Figure 2
Forest plot of PPI discontinuation rates among TIF 2.0 versus PPI and/or sham RCTs. M-H, Mantel-Haenszel test; PPI, proton pump inhibitor; RCTs, randomized controlled trials; TIF 2.0, transoral incisionless fundoplication 2.0 (Esophyx 2.0).
Figure 3
Figure 3
Forest plot of cohort studies showing PPI use at baseline and after TIF 2.0. M-H, Mantel-Haenszel test; PPI, proton pump inhibitor; TIF 2.0, transoral incisionless fundoplication 2.0 (Esophyx 2.0).
Figure 4
Figure 4
Forest plot of cohort studies showing acid exposure time at baseline and after TIF 2.0. IV, Independent variable; TIF 2.0, transoral incisionless fundoplication 2.0 (Esophyx 2.0).
Figure 5
Figure 5
Forest plot of normalization of esophageal acid exposure among TIF versus PPI and/or sham RCTs. M-H, Mantel-Haenszel test; PPI, proton pump inhibitor; RCTs, randomized controlled trials; TIF 2.0, transoral incisionless fundoplication 2.0 (Esophyx 2.0).
Figure 6
Figure 6
Forest plot of symptom resolution among RCTs of TIF versus medical therapy and/or sham intervention. M-H, Mantel-Haenszel test; PPI, proton pump inhibitor; RCTs, randomized controlled trials; TIF 2.0, transoral incisionless fundoplication 2.0 (Esophyx 2.0).
Figure 7
Figure 7
Forest plot of cohort studies showing improvement in GERD-HRQL scores between before and after TIF 2.0. GERD-HRQL, GERD-health-related quality of life; IV, independent variable; TIF 2.0, transoral incisionless fundoplication 2.0 (Esophyx 2.0).
Figure 8
Figure 8
Forest plot of adverse events among RCTs of TIF versus medical therapy and/or sham intervention. M-H, Mantel-Haenszel test; PPI, proton pump inhibitor; RCTs, randomized controlled trials; TIF 2.0, transoral incisionless fundoplication 2.0 (Esophyx 2.0).
Figure 9
Figure 9
Forest plot of serious and significant adverse events among RCTs of TIF versus medical therapy and/or sham intervention. M-H, Mantel-Haenszel test; PPI, proton pump inhibitor; RCTs, randomized controlled trials; TIF 2.0, transoral incisionless fundoplication 2.0 (Esophyx 2.0).
Figure 10
Figure 10
Forest plot of studies of PPI use at baseline (before cTIF) and after cTIF. cTIF, Combined hiatal hernia repair and transoral incisionless fundoplication; M-H, Mantel-Haenszel test; PPI, proton pump inhibitor.
Figure 11
Figure 11
Forest plot of GERD-HRQL score at baseline and after cTIF. cTIF, Combined hiatal hernia repair and transoral incisionless fundoplication; GERD-HRQL, GERD health-related quality of life; IV, independent variable.
Figure 12
Figure 12
Forest plot of PPI discontinuation rate among RCTs examining Stretta and PPI and/or sham therapy. M-H, Mantel-Haenszel test; PPI, proton pump inhibitor; RCTs, randomized controlled trials.
Figure 13
Figure 13
Forest plot of acid exposure time among RCTs examining Stretta and PPI and/or sham therapy. IV, Independent variable; PPI, proton pump inhibitor; RCTs, randomized controlled trials.
Figure 14
Figure 14
Forest plot of normalization of esophageal acid exposure rate among RCTs examining Stretta and PPI and/or sham therapy. M-H, Mantel-Haenszel test; PPI, proton pump inhibitor; RCTs, randomized controlled trials.
Figure 15
Figure 15
Forest plot of symptom resolution rate among RCTs examining Stretta and PPI and/or sham therapy. M-H, Mantel-Haenszel test; PPI, proton pump inhibitor; RCTs, randomized controlled trials.
Figure 16
Figure 16
Forest plot of difference in GERD-HRQL scores among RCTs examining Stretta and PPI and/or sham therapy. GERD-HRQL, GERD-health-related quality of life; IV, independent variable; PPI, proton pump inhibitor; RCTs, randomized controlled trials.
Figure 17
Figure 17
Forest plot of adverse events among RCTs of Stretta versus medical therapy and/or sham intervention. M-H, Mantel-Haenszel test; PPI, proton pump inhibitor; RCTs, randomized controlled trials.
Figure 18
Figure 18
Forest plot of serious adverse events among RCTs of Stretta versus medical therapy and/or sham intervention. M-H, Mantel-Haenszel test; PPI, proton pump inhibitor; RCTs, randomized controlled trials.
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