What is the classification of the Gastroesophageal (GE) flap valve according to the Hill grade?

From the Guidelines

The gastroesophageal flap valve is classified using the Hill grade system, which assesses the integrity of the valve during endoscopy, as recommended by the AGA clinical practice update 1. The Hill classification system is a crucial tool in evaluating the gastroesophageal flap valve (GEFV) and its role in gastroesophageal reflux disease (GERD).

• The system grades the GEFV from Grade I to Grade IV based on its appearance during endoscopy.
• Grade I represents a normal, intact valve with a prominent fold of tissue closely wrapped around the endoscope.
• Grade II shows a slightly diminished valve with a less prominent fold.
• Grade III indicates an abnormal valve with the fold not closing around the endoscope.
• Grade IV represents a severely compromised valve with no muscular fold and a wide-open gastroesophageal junction. This grading system is clinically important because higher grades (III and IV) correlate with increased GERD severity, as the compromised valve allows stomach contents to reflux more easily into the esophagus, as noted in the AGA clinical practice update 2. The anatomical basis for this grading relates to the integrity of the angle of His and the muscular components that normally create a one-way valve mechanism at the gastroesophageal junction. Endoscopists use this classification to help assess GERD risk, guide treatment decisions, and evaluate the need for anti-reflux procedures, as part of a complete endoscopic evaluation of GERD symptoms, which includes inspection for erosive esophagitis, diaphragmatic hiatus, axial hiatus hernia length, and inspection for Barrett’s esophagus 1.

From the Research

Gastroesophageal Flap Valve Classification

The gastroesophageal flap valve (GEFV) is classified using Hill's classification, which provides a reproducible endoscopic grading system for esophagogastric junction morphology and competence 3. The classification system grades the GEFV from I to IV, with grades I and II considered normal and grades III and IV considered abnormal.

Hill's Classification Grades

The grades in Hill's classification are defined as follows:

• Grade I: The GEFV is normal, with a well-defined flap valve.
• Grade II: The GEFV is slightly abnormal, with a partially defined flap valve.
• Grade III: The GEFV is abnormal, with a poorly defined flap valve.
• Grade IV: The GEFV is severely abnormal, with no visible flap valve.

Association with Gastroesophageal Reflux Disease (GERD)

Studies have shown that an abnormal GEFV, as indicated by Hill's classification III/IV, is associated with an increased risk of symptomatic GERD and erosive esophagitis 3, 4. The specificity of abnormal GEFV for symptomatic GERD was found to be 73.3% and 75.7% for erosive esophagitis in symptomatic GERD 3.

Key Findings

• An abnormal GEFV is associated with an increased risk of gastroesophageal and gastropharyngeal reflux 4.
• The endoscopic grading of the GEFV is easy and provides useful information about the status of gastroesophageal and gastropharyngeal reflux 4.
• Hill's classification is a useful tool for predicting the risk of GERD and erosive esophagitis 3.