Summary

The ACG 2022 GERD guideline updates the 2013 version with evidence-based recommendations spanning diagnosis, pharmacologic and lifestyle therapy, refractory disease, extraesophageal symptoms, and surgical/endoscopic interventions. PPIs remain first-line medical therapy, but the document emphasizes stricter criteria for diagnosing GERD before chronic acid suppression, more rigorous workup of “refractory” symptoms (since most are not truly reflux-related), and provides reassurance regarding the safety of long-term PPI use based on the COMPASS trial. New attention is given to magnetic sphincter augmentation (MSA), transoral incisionless fundoplication (TIF), and the limited role of surgery for extraesophageal symptoms.

Key Recommendations

Empirically treat patients with classic GERD symptoms (heartburn, regurgitation) without alarm features using an 8-week PPI trial taken 30-60 minutes before the first meal of the day.
Perform endoscopy promptly in patients with alarm features (dysphagia, weight loss, bleeding, vomiting, anemia) and stop PPIs for 2-4 weeks before diagnostic endoscopy when feasible to maximize yield for EE and EoE.
Diagnose GERD objectively by LA grade B EE with typical symptoms/PPI response, LA grade C/D EE, biopsy-proven Barrett’s >3 cm, or abnormal ambulatory reflux monitoring; LA grade A alone is not diagnostic.
Perform ambulatory reflux monitoring off PPIs (stopped 7 days) before considering antireflux surgery/endoscopic therapy when GERD has not been objectively established.
Maintain patients with LA grade C/D EE and Barrett’s esophagus on long-term PPI therapy indefinitely; use lowest effective dose and consider on-demand or step-down therapy in NERD.
Do not use barium radiography, laryngoscopy, salivary pepsin, or oropharyngeal pH testing as diagnostic tests for GERD or LPR.
Do not diagnose extraesophageal GERD (cough, laryngitis, asthma, hoarseness) based on symptoms or PPI response alone — pursue parallel non-GERD evaluation and require objective reflux evidence before invasive therapy.
Perform HRM before any antireflux surgery/endoscopic procedure to exclude achalasia and absent contractility.
In PPI-refractory patients, first optimize PPI dosing/timing/adherence, then perform endoscopy off PPIs and impedance-pH testing (on PPI if prior objective GERD, off PPI if diagnosis unestablished).
Offer antireflux surgery (laparoscopic fundoplication or MSA) to patients with objectively confirmed GERD who respond to PPIs but prefer surgery, or who have truly refractory reflux-related symptoms; RYGB is preferred in obese patients (BMI >35).
Add bedtime H2RA as-needed for documented nocturnal acid breakthrough on PPIs; consider baclofen 5-20 mg TID for refractory reflux with objective evidence.
For pregnancy, start with lifestyle measures, then antacids/alginates/sucralfate; H2RAs and PPIs (except omeprazole) are category B.

Thresholds & Doses

PPI timing: 30-60 minutes before breakfast (once daily) or before breakfast and dinner (twice daily).
PPI trial duration: 8 weeks for symptom relief and EE healing.
Refractory GERD: persistent heartburn/regurgitation despite 8 weeks of double-dose (twice-daily) PPI therapy.
Stop PPIs 2-4 weeks before diagnostic endoscopy; stop 7 days before reflux monitoring off-therapy.
Wireless pH capsule monitoring duration: 48-96 hours; catheter pH/impedance: 24 hours.
Symptom Index (SI) positive: ≥50%; Symptom Association Probability (SAP) positive: >95%.
Pathologic esophageal acid exposure time: >4% (>12% strongly predicts surgical success in extraesophageal GERD).
Barrett’s esophagus diagnostic of GERD: segment >3 cm with intestinal metaplasia on biopsy.
Head-of-bed elevation and avoiding meals within 3 hours of bedtime recommended for nocturnal symptoms.
Baclofen dosing: 5-20 mg three times daily for refractory reflux.
Omeprazole-equivalent potencies: pantoprazole 0.23, lansoprazole 0.90, omeprazole 1.00, esomeprazole 1.60, rabeprazole 1.82.
BMI >35 increases GERD prevalence up to 6-fold vs normal BMI; weight loss with BMI reduction ≥3.5 reduces GERD symptoms by ~40%.
MSA contraindication: MRI scanners >1.5 Tesla; device erosion risk 0.3% at 4 years.
Laparoscopic antireflux surgery: ~4% acute complication rate, ~17.7% GERD recurrence at 5 years.

Citations

Diagnosis of GERD / Endoscopy section — LA grading and criteria for endoscopic GERD diagnosis
Reflux monitoring section — on vs off PPI testing, SI/SAP thresholds
GERD Medical Management / Proton pump inhibitors — PPI dosing, timing, maintenance indications
Diet and lifestyle changes section / Table 3 — lifestyle modification evidence
Extraesophageal GERD section / Figure 2 — diagnostic and treatment approach to LPR, cough, asthma
Refractory GERD section / Figures 3A-3B / Table 4 — workup and mechanisms of PPI-refractory symptoms
Surgical and Endoscopic Options — fundoplication, MSA, RYGB, TIF, Stretta
Long-term PPI Issues / Table 5 — putative adverse effects and COMPASS trial (Moayyedi 2019) safety data