What is the recommended evaluation and treatment approach for a patient with suspected Gastroesophageal Reflux Disease (GERD) or esophagitis, using the Hills grading system?

Hill Grading in GERD Evaluation

Hill grading of the gastroesophageal flap valve should be routinely assessed during every endoscopy performed for GERD evaluation, as it is a mandatory component of complete endoscopic assessment according to current AGA guidelines. 1

What Hill Grading Measures

Hill grading assesses the integrity of the gastroesophageal flap valve at the diaphragmatic hiatus during endoscopy. 1 This anatomical assessment provides critical information about the anti-reflux barrier mechanism and helps predict disease severity and treatment response. 1

When to Perform Hill Grading Assessment

Complete endoscopic evaluation of GERD symptoms must include inspection of the diaphragmatic hiatus (Hill grade of flap valve), along with assessment for erosive esophagitis (Los Angeles classification), axial hiatus hernia length, and Barrett's esophagus (Prague classification with biopsy when present). 1

Specific Clinical Scenarios Requiring Endoscopy with Hill Grading:

• PPI non-responders: When heartburn, regurgitation, or non-cardiac chest pain fail to respond adequately to PPI trial after 4-8 weeks 1

• Alarm symptoms present: Any patient presenting with dysphagia, odynophagia, weight loss, or gastrointestinal bleeding 1

• Long-term PPI users without confirmed diagnosis: Patients on chronic PPI therapy for unproven GERD should undergo endoscopy within 12 months of PPI initiation to establish appropriateness of long-term therapy 1

• Pre-surgical evaluation: All patients being considered for anti-reflux procedures (fundoplication, magnetic sphincter augmentation, or transoral incisionless fundoplication) require complete endoscopic assessment including Hill grading 1

Integration with Other Endoscopic Findings

The Complete GERD Endoscopy Report Must Document:

1. Erosive esophagitis severity: Grade according to Los Angeles classification (Grade A through D) when present 1

2. Hill grade of flap valve: Assessment of the gastroesophageal junction competence 1

3. Hiatus hernia: Measure and document axial length in centimeters 1

4. Barrett's esophagus: Grade according to Prague classification and obtain biopsies when present 1

Clinical Decision-Making Based on Endoscopic Findings

If Los Angeles Grade B or Higher Esophagitis Found:

• This constitutes conclusive GERD evidence and no further pH monitoring is needed 1

• Optimize PPI therapy to control symptoms 1

• Continue PPI indefinitely if erosive disease present at baseline 1

• Consider anti-reflux intervention for medication-refractory symptoms 1

If No Erosive Disease or Only Los Angeles Grade A:

• Proceed to prolonged wireless pH monitoring off PPI (96-hour preferred) performed 2-7 days after stopping PPI 1

• Los Angeles Grade A esophagitis alone does not constitute erosive reflux disease, as it can be seen in healthy asymptomatic volunteers 1

If Long-Segment Barrett's Esophagus (≥3 cm):

• This constitutes conclusive GERD evidence 1

• Institute surveillance program with multiple biopsies 2

• No pH monitoring needed for GERD confirmation 1

Common Pitfalls to Avoid

Do not rely on non-erosive endoscopic changes such as erythema alone, as these findings lack reproducibility and diagnostic value for GERD. 2 Only document mucosal breaks, ulcers, strictures, and metaplasia. 2

Do not obtain tissue samples from endoscopically normal esophageal mucosa to diagnose GERD or exclude Barrett's esophagus in adults, as this does not add diagnostic value. 3

Do not perform routine follow-up endoscopy unless severe erosive esophagitis (Los Angeles Grade C or D) is present, in which case repeat endoscopy after at least 8 weeks of PPI therapy is suggested to exclude underlying Barrett's esophagus or dysplasia. 3

Role in Surgical Planning

Hill grading assessment is particularly critical when evaluating candidacy for invasive anti-reflux procedures. 1 The integrity of the anti-reflux barrier (as assessed by Hill grade), combined with hiatus hernia size and erosive disease severity, helps determine which patients are optimal candidates for:

• Laparoscopic fundoplication 1
• Magnetic sphincter augmentation 1
• Transoral incisionless fundoplication 1

All surgical candidates require confirmatory evidence of pathologic GERD, exclusion of achalasia, and assessment of esophageal peristaltic function in addition to complete endoscopic evaluation. 1