Endoscopic Hill grade is associated with gastroesophageal reflux (GER) in children and adolescents suspected of having gastroesophageal reflux disease (GERD), according to a study in the Journal of Neurogastroenterology and Motility.

Investigators sought to evaluate the relationship between Hill grade confirmed with esophagogastroduodenoscopy (EGD) and the degree of reflux through multichannel intraluminal impedance-pH monitoring (MII-pH). The retrospective review included 105 children and adolescents suspected of having GERD from March 1, 2013, to July 31, 2019, at a hospital in Korea. Eligible participants were those aged less than 18 years who had undergone EGD and MII-pH.

A total of 105 children (median age, 6.1 years; interquartile range, 3.3-11.6 years; 54% male) were included; 40 patients (38.1%) had severe underlying neurologic diseases, and 16 patients (15.2%) had endoscopic erosive esophagitis. Underlying neurologic diseases included cerebral palsy (n=16; 40%), infantile spasm (n=2; 5%), Lennox-Gastaut syndrome (n=8; 20%), and brain injury (n=8; 20%).

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The study authors identified Hill grades 1, 2, 3, and 4 in 56 patients (53.3%), 22 patients (22.0%), 16 patients (15.2%), and 11 patients (10.5%), respectively, and found that the proportion of neurologic disease (P =.002) and endoscopic erosive esophagitis (P <.001) increased significantly as Hill grade increased.

In addition, the 24-hour MII-pH test findings of acid exposure index, bolus exposure index, number of reflux episodes, and number of GER reaching proximal extent increased significantly according to the gradual increase in endoscopic Hill grade (all P <.001).

Linear regression analysis of the Hill grades and MII-pH results showed that an increase in the Hill grade by 1 increased the acid exposure index by 2.0% (P <.001), the bolus exposure index by 0.7% (P <.001), the number of reflux episodes by 18.9 episodes (P <.001), and the amount of GER reaching the proximal esophagus by 10.5 episodes (P <.001) on average, all statistically significant findings.

Study limitations included its retrospective design. Additionally, although 1 investigator reviewed the previous endoscopic images to evaluate Hill grade, the accuracy may have decreased as Hill grade was not assessed at the time of examination in all participants. Furthermore, the symptom index was not included in the MII-pH results.

“Estimating the degree of GER by applying Hill grade in the retroflexion view may be useful in practice when evaluating children suspected with GERD,” the researchers concluded.


Yoo IH, Joo JY, Yang HR. Usefulness of endoscopic hill grade in evaluating children suspected of having gastroesophageal reflux disease. J Neurogastroenterol Motil. 2021;27(2):191-197. doi: 10.5056/jnm20033