Correlation of the Endoscopic Gastroesophageal Flap Valve with Gastroesophageal Reflux Disease

INTRODUCTION: Hill Grade (HG) characterizes the gastroesophageal flap valve and abnormal HGs (III/IV) correlate with GERD. Although considered normal, many patients with HG II have GERD in clinical practice. The aim of this study was to correlate the incidence of GERD across HGs and determine the incidence of GERD in patients with HG II. METHODS: A retrospective review was performed on 365 patients who underwent EGD and BRAVO pH monitoring between August 2018 and August 2021. Of 365 patients, 187 (51.2%) had a HG reported and were further reviewed for the association with pathologic acid exposure defined as overall acid exposure time (AET): 4.9% and DeMeester score (DMS): 14.7. RESULTS: Of the 187 patients, 37 (19.8%) had HG I; 80 (42.8%) HG II; 49 (26.2%) HG III, and 21 (11.2%) HG IV. The proportion of abnormal AET increases with increasing HG (p = 0.023): I (37.8%), II (55.0%), III (63.7%), IV (76.2%); and the median AET also increases with HG (p = 0.008): I (1.6%), II (5.9%), III (8.3%), IV (9.5%). The proportion of abnormal DMS increases with HG (p = 0.022): I (43.2%), II (66.3%), III (71.4%), IV (76.2%); and the median DMS also increases with HG (p = 0.003): I (7.2), II (20.6), III (27.6), IV (34.3) (Table 1). Table 1. - Comparison of the Findings of 24-Hour pH Monitoring According to Hill Grade Variable Hill grade Median Mean Kruskal-Wallis test p Value DeMeester score 1 7.2 18.01 0.003 2 20.60 27.29 3 27.60 37.02 4 34.30 32.44 Acid exposure time overall (%) 1 1.6 5.11 0.008 2 5.95 7.50 3 8.30 10.34 4 9.50 8.96 CONCLUSION: Increasing HG is associated with higher median AET and DMS. HG II, which has been considered normal, correlates with pathologic reflux. Efforts are needed to educate endoscopists on the importance of accurately documenting the HG within the context of GERD management.