Hill Grading in GERD Evaluation

Introduction to Hill Grading

The American Gastroenterological Association recommends that 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 1, 2, 3

Hill grading assesses the integrity of the gastroesophageal flap valve at the diaphragmatic hiatus during endoscopy, providing critical information about the anti-reflux barrier mechanism and helping predict disease severity and treatment response 1, 2, 3

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, 2, 3
The American Gastroenterological Association suggests that patients with symptoms such as heartburn, regurgitation, or non-cardiac chest pain that fail to respond adequately to PPI trial after 4-8 weeks should undergo endoscopy with Hill grading 1, 2, 3
Patients presenting with dysphagia, odynophagia, weight loss, or gastrointestinal bleeding should also undergo endoscopy with Hill grading 1, 2, 3
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, 2

The complete GERD endoscopy report must document erosive esophagitis severity, Hill grade of flap valve, hiatus hernia size, and Barrett's esophagus grade 1, 2, 3
Erosive esophagitis severity should be graded according to the Los Angeles classification (Grade A through D) when present 1, 2, 3
Hiatus hernia size should be measured and documented in centimeters 1, 2, 3
Barrett's esophagus should be graded according to the Prague classification and biopsies should be obtained when present 1, 2, 3

If Los Angeles Grade B or higher esophagitis is found, this constitutes conclusive GERD evidence and no further pH monitoring is needed 1, 2, 3, 4, 5
If no erosive disease or only Los Angeles Grade A is found, prolonged wireless pH monitoring off PPI (96-hour preferred) should be performed 2-7 days after stopping PPI 1, 2, 3, 7
If long-segment Barrett's esophagus (≥3 cm) is found, this constitutes conclusive GERD evidence and no pH monitoring is needed 1, 2, 3

Hill grading assessment is critical when evaluating candidacy for invasive anti-reflux procedures, such as laparoscopic fundoplication, magnetic sphincter augmentation, and transoral incisionless fundoplication 1, 2, 3
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, 2, 3