Esophagus/Reflux, in full.

ACG 2025 (GRADE) is still the governing guideline. The ASGE 2026 consensus Part 2 (modified Delphi, 28 statements at ≥80% agreement; not GRADE) adds endoscopic and pediatric detail without contradicting it. DIAGNOSIS: symptoms of esophageal dysfunction plus ≥15 eos/hpf after excluding other causes of esophageal eosinophilia. A PPI trial is not a diagnostic criterion (PPI-REE abandoned). Do the initial diagnostic EGD off PPI, topical steroid and dietary therapy (ACG key concept; ASGE consensus, which gives no washout duration). Initial assessment is a standard EGD, not a less-invasive modality, so that full biopsies and dilation are possible (ASGE). Take ≥6 esophageal biopsies from ≥2 levels in anyone with symptoms or endoscopic findings consistent with EoE, targeting visible lesions. In CHILDREN with suspected EoE, also biopsy the stomach and duodenum (ASGE). Use EREFS at every endoscopy and report a quantified peak eosinophil count (ACG strong/low; ASGE). TREATMENT (ACG): swallowed topical steroids STRONG/moderate; high-dose PPI CONDITIONAL/low; empiric elimination diet CONDITIONAL/low. Choose a single initial therapy by shared decision-making. Fluticasone or budesonide are both reasonable. Adult doses: PPI double the reflux dose (e.g., omeprazole 20 mg BID or 40 mg daily); budesonide 2-4 mg/day (BOS 2 mg BID); fluticasone 1,760 mcg/day divided. Pediatric doses: PPI 2 mg/kg/day; budesonide 1-2 mg/day; fluticasone 110-880 mcg/day. Allergy testing is not used to direct diets. A 1FED/2FED step-up diet with a dietitian is acceptable, with endoscopic and biopsy confirmation after each reintroduced food. Dupilumab is CONDITIONAL for PPI-nonresponsive patients aged ≥12 (moderate) and for ages 1-11 at ≥15 kg (low). Weight-band dosing: 15-<30 kg 200 mg q2w; 30-<40 kg 300 mg q2w; ≥40 kg 300 mg weekly. Recommendations AGAINST: omalizumab, cromolyn, montelukast. No recommendation for cendakimab, benralizumab, lirentelimab, mepolizumab or reslizumab. DILATION: an adjunct to anti-inflammatory therapy for strictures causing dysphagia (ACG conditional/low). Start low and go slow; target ≥16 mm in adults and adolescents over ≥1 session. In children, ASGE supports dilation of symptomatic strictures or a narrow-caliber esophagus regardless of disease activity, using the same start-low/go-slow approach. MAINTENANCE: continue effective therapy (ACG STRONG despite low evidence) at the lowest effective dose. MONITORING: judge response on symptoms, endoscopy and histology together, never symptoms alone. Assess response endoscopically at 8-12 weeks after starting a PPI or topical steroid. For diet, ACG says 8-12 weeks and ASGE says 6-8 weeks. For dupilumab or biologics, assess at 12-24 weeks (ASGE: up to 24 weeks). Allow appropriate washout or timing after any treatment change before the follow-up EGD (ASGE). Take monitoring biopsies from the most severe-appearing lesions (rings, furrows, exudates) (ASGE). Monitoring biopsies may be limited to the esophagus when prior gastric and duodenal biopsies were normal and nothing new suggests other pathology (ASGE). The histologic response threshold of <15 eos/hpf is a 'may consider' target, read alongside endoscopic and symptom findings. Shorten follow-up after complications. Care gaps of ≥2 years are associated with fibrostenosis. PEDIATRIC (ACG): esophagram for children with dysphagia to assess fibrostenotic disease; feeding therapy and dietitian for feeding dysfunction; growth, development and nutrition are treatment goals.

ACG 2025 (GRADE) is still the governing guideline. The ASGE 2026 consensus Part 2 (modified Delphi, 28 statements at ≥80% agreement; not GRADE) adds endoscopic and pediatric detail without contradicting it. DIAGNOSIS: symptoms of esophageal dysfunction plus ≥15 eos/hpf after excluding other causes of esophageal eosinophilia. A PPI trial is not a diagnostic criterion (PPI-REE abandoned). Do the initial diagnostic EGD off PPI, topical steroid and dietary therapy (ACG key concept; ASGE consensus, which gives no washout duration). Initial assessment is a standard EGD, not a less-invasive modality, so that full biopsies and dilation are possible (ASGE). Take ≥6 esophageal biopsies from ≥2 levels in anyone with symptoms or endoscopic findings consistent with EoE, targeting visible lesions. In CHILDREN with suspected EoE, also biopsy the stomach and duodenum (ASGE). Use EREFS at every endoscopy and report a quantified peak eosinophil count (ACG strong/low; ASGE). TREATMENT (ACG): swallowed topical steroids STRONG/moderate; high-dose PPI CONDITIONAL/low; empiric elimination diet CONDITIONAL/low. Choose a single initial therapy by shared decision-making. Fluticasone or budesonide are both reasonable. Adult doses: PPI double the reflux dose (e.g., omeprazole 20 mg BID or 40 mg daily); budesonide 2-4 mg/day (BOS 2 mg BID); fluticasone 1,760 mcg/day divided. Pediatric doses: PPI 2 mg/kg/day; budesonide 1-2 mg/day; fluticasone 110-880 mcg/day. Allergy testing is not used to direct diets. A 1FED/2FED step-up diet with a dietitian is acceptable, with endoscopic and biopsy confirmation after each reintroduced food. Dupilumab is CONDITIONAL for PPI-nonresponsive patients aged ≥12 (moderate) and for ages 1-11 at ≥15 kg (low). Weight-band dosing: 15-<30 kg 200 mg q2w; 30-<40 kg 300 mg q2w; ≥40 kg 300 mg weekly. Recommendations AGAINST: omalizumab, cromolyn, montelukast. No recommendation for cendakimab, benralizumab, lirentelimab, mepolizumab or reslizumab. DILATION: an adjunct to anti-inflammatory therapy for strictures causing dysphagia (ACG conditional/low). Start low and go slow; target ≥16 mm in adults and adolescents over ≥1 session. In children, ASGE supports dilation of symptomatic strictures or a narrow-caliber esophagus regardless of disease activity, using the same start-low/go-slow approach. MAINTENANCE: continue effective therapy (ACG STRONG despite low evidence) at the lowest effective dose. MONITORING: judge response on symptoms, endoscopy and histology together, never symptoms alone. Assess response endoscopically at 8-12 weeks after starting a PPI or topical steroid. For diet, ACG says 8-12 weeks and ASGE says 6-8 weeks. For dupilumab or biologics, assess at 12-24 weeks (ASGE: up to 24 weeks). Allow appropriate washout or timing after any treatment change before the follow-up EGD (ASGE). Take monitoring biopsies from the most severe-appearing lesions (rings, furrows, exudates) (ASGE). Monitoring biopsies may be limited to the esophagus when prior gastric and duodenal biopsies were normal and nothing new suggests other pathology (ASGE). The histologic response threshold of <15 eos/hpf is a 'may consider' target, read alongside endoscopic and symptom findings. Shorten follow-up after complications. Care gaps of ≥2 years are associated with fibrostenosis. PEDIATRIC (ACG): esophagram for children with dysphagia to assess fibrostenotic disease; feeding therapy and dietitian for feeding dysfunction; growth, development and nutrition are treatment goals.

In patients with classic GERD symptoms (heartburn, regurgitation) and no alarm symptoms, give an 8-week trial of empiric PPI ONCE DAILY before a meal (strong, moderate evidence); administer PPI 30-60 minutes before a meal rather than at bedtime (strong, moderate). Endoscopy is the FIRST test in patients presenting with dysphagia or other alarm symptoms, the guideline names weight loss and GI bleeding, and also in patients with multiple risk factors for Barrett's esophagus (strong, low). If classic symptoms respond to the 8-week trial, attempt to discontinue the PPI (conditional, low); for patients without erosive esophagitis or Barrett's whose symptoms resolved, an attempt at discontinuation should be made; patients requiring maintenance should take the lowest effective dose. If symptoms do not respond adequately to the 8-week trial, or return on discontinuation, perform diagnostic endoscopy, ideally after PPIs are stopped for 2-4 weeks (strong, low). Where GERD is suspected but unclear and endoscopy shows no objective evidence, perform reflux monitoring OFF therapy to establish the diagnosis (strong, low); conversely, do NOT perform off-therapy reflux monitoring solely as a diagnostic test in patients already known to have LA grade C or D esophagitis or long-segment Barrett's, because the diagnosis is already established (strong, low). In refractory GERD, optimize PPI therapy first (strong, moderate); then pH monitoring OFF PPIs if GERD was not previously established by pH study, long-segment Barrett's, or LA grade C/D esophagitis, versus impedance-pH ON PPIs where GERD is already established but symptoms persist on twice-daily PPI (both conditional, low). Before antireflux surgery or endoscopic therapy, HRM is recommended to rule out achalasia and absent contractility, with provocative testing (e.g., multiple rapid swallows) to identify contractile reserve in ineffective esophageal motility; on-therapy reflux monitoring is suggested before intervention in patients with prior objective GERD findings who remain symptomatic. Antireflux surgery by an experienced surgeon is an option for patients with OBJECTIVE evidence of GERD, with severe esophagitis (LA C/D), large hiatal hernia, or persistent troublesome symptoms benefiting most; TIF is suggested only for troublesome regurgitation or heartburn in patients who do not wish to undergo antireflux surgery and who are WITHOUT severe esophagitis (LA C/D) or hiatal hernia >2 cm. For extraesophageal symptoms WITHOUT typical GERD symptoms, perform reflux testing BEFORE starting PPI therapy (strong, moderate); with concomitant typical symptoms, consider twice-daily PPI for 8-12 weeks before further testing (conditional, low). Lifestyle: weight loss in overweight/obese patients (strong, moderate); avoid meals within 2-3 hours of bedtime, avoid tobacco, avoid trigger foods, and elevate the head of the bed for nighttime symptoms (all conditional, low).

ACG 2025 (GRADE) is still the governing guideline. The ASGE 2026 consensus Part 2 (modified Delphi, 28 statements at ≥80% agreement; not GRADE) adds endoscopic and pediatric detail without contradicting it. DIAGNOSIS: symptoms of esophageal dysfunction plus ≥15 eos/hpf after excluding other causes of esophageal eosinophilia. A PPI trial is not a diagnostic criterion (PPI-REE abandoned). Do the initial diagnostic EGD off PPI, topical steroid and dietary therapy (ACG key concept; ASGE consensus, which gives no washout duration). Initial assessment is a standard EGD, not a less-invasive modality, so that full biopsies and dilation are possible (ASGE). Take ≥6 esophageal biopsies from ≥2 levels in anyone with symptoms or endoscopic findings consistent with EoE, targeting visible lesions. In CHILDREN with suspected EoE, also biopsy the stomach and duodenum (ASGE). Use EREFS at every endoscopy and report a quantified peak eosinophil count (ACG strong/low; ASGE). TREATMENT (ACG): swallowed topical steroids STRONG/moderate; high-dose PPI CONDITIONAL/low; empiric elimination diet CONDITIONAL/low. Choose a single initial therapy by shared decision-making. Fluticasone or budesonide are both reasonable. Adult doses: PPI double the reflux dose (e.g., omeprazole 20 mg BID or 40 mg daily); budesonide 2-4 mg/day (BOS 2 mg BID); fluticasone 1,760 mcg/day divided. Pediatric doses: PPI 2 mg/kg/day; budesonide 1-2 mg/day; fluticasone 110-880 mcg/day. Allergy testing is not used to direct diets. A 1FED/2FED step-up diet with a dietitian is acceptable, with endoscopic and biopsy confirmation after each reintroduced food. Dupilumab is CONDITIONAL for PPI-nonresponsive patients aged ≥12 (moderate) and for ages 1-11 at ≥15 kg (low). Weight-band dosing: 15-<30 kg 200 mg q2w; 30-<40 kg 300 mg q2w; ≥40 kg 300 mg weekly. Recommendations AGAINST: omalizumab, cromolyn, montelukast. No recommendation for cendakimab, benralizumab, lirentelimab, mepolizumab or reslizumab. DILATION: an adjunct to anti-inflammatory therapy for strictures causing dysphagia (ACG conditional/low). Start low and go slow; target ≥16 mm in adults and adolescents over ≥1 session. In children, ASGE supports dilation of symptomatic strictures or a narrow-caliber esophagus regardless of disease activity, using the same start-low/go-slow approach. MAINTENANCE: continue effective therapy (ACG STRONG despite low evidence) at the lowest effective dose. MONITORING: judge response on symptoms, endoscopy and histology together, never symptoms alone. Assess response endoscopically at 8-12 weeks after starting a PPI or topical steroid. For diet, ACG says 8-12 weeks and ASGE says 6-8 weeks. For dupilumab or biologics, assess at 12-24 weeks (ASGE: up to 24 weeks). Allow appropriate washout or timing after any treatment change before the follow-up EGD (ASGE). Take monitoring biopsies from the most severe-appearing lesions (rings, furrows, exudates) (ASGE). Monitoring biopsies may be limited to the esophagus when prior gastric and duodenal biopsies were normal and nothing new suggests other pathology (ASGE). The histologic response threshold of <15 eos/hpf is a 'may consider' target, read alongside endoscopic and symptom findings. Shorten follow-up after complications. Care gaps of ≥2 years are associated with fibrostenosis. PEDIATRIC (ACG): esophagram for children with dysphagia to assess fibrostenotic disease; feeding therapy and dietitian for feeding dysfunction; growth, development and nutrition are treatment goals.

Perform individual gastric risk assessment and staging of precancerous conditions at first-time gastroscopy, irrespective of the patient's country of origin. Use high quality endoscopy with virtual chromoendoscopy (VCE), after proper training, for screening, diagnosis and staging of atrophy and intestinal metaplasia and after endoscopic therapy; VCE guides the biopsy site, with random biopsies taken only when there are no endoscopically suspected changes. Take biopsies from at least two topographic sites, 2 from the antrum/incisura and 2 from the corpus, VCE-guided, in two separate, clearly labeled vials; an additional incisura biopsy is optional, not required. Stage with validated endoscopic classifications of atrophy (e.g. Kimura-Takemoto) or intestinal metaplasia (e.g. EGGIM) to stratify gastric cancer risk (suggestion, weaker than the biopsy recommendation). Follow up patients with extensive endoscopic changes (Kimura C3+ or EGGIM 5+) OR an advanced histological stage that reaches OLGA/OLGIM III/IV, severe atrophy or intestinal metaplasia and/or significant changes in both antrum and corpus rising to stage III/IV, not any intestinal metaplasia or any antrum-plus-corpus involvement on its own, with high quality endoscopy every 3 years, irrespective of country of origin (strong recommendation, moderate quality). Propose NO surveillance for patients with mild to moderate atrophy or intestinal metaplasia restricted to the antrum, in the absence of endoscopic signs of extensive lesions or other risk factors (family history of gastric cancer, incomplete intestinal metaplasia, persistent H. pylori infection), the guideline states this group constitutes most individuals found in clinical practice. Eradicate H. pylori in all patients with precancerous conditions and after endoscopic or surgical therapy. Discontinue or do not start gastric cancer screening or surveillance in asymptomatic individuals over 80, and weigh comorbidities when planning treatment of superficial lesions. Advise smoking cessation; low-dose daily aspirin may be considered for gastric cancer prevention only in selected individuals already at high cardiovascular risk. For visible neoplasia, use ESD for differentiated lesions clinically staged as dysplastic (low or high grade) or intramucosal carcinoma (any size if not ulcerated, or ≤30 mm if ulcerated), with EMR an alternative for Paris 0-IIa lesions ≤10 mm with low likelihood of malignancy. At the population level, endoscopic screening is suggested every 2-3 years in high-risk regions (age-standardized rate >20 per 100,000 person-years), every 5 years in intermediate-risk regions (ASR 10-20) only if cost-effectiveness has been proven, and not at all in low-risk regions (ASR <10).