July 20: Researchers from UTHealth Houston have helped develop a new classification system designed to bring greater consistency and precision to how physicians evaluate one of the body’s most important barriers against acid reflux.
The work, led by Nirav Thosani, MD, MHA, professor of gastroenterology and the Atilla Ertan, MD, Endowed Chair in Gastroenterology, Hepatology, and Nutrition at McGovern Medical School at UTHealth Houston, focuses on the esophagogastric junction, the area where the esophagus meets the stomach and functions as a valve to prevent stomach contents from flowing backward. When the junction becomes disrupted, patients can develop gastroesophageal reflux disease, one of the most common digestive conditions worldwide.
For 30 years, physicians have relied on the Hill grade to assess the junction during endoscopy. While widely used, the system depends heavily on subjective interpretation and evaluates only one component of the anatomy. As a result, gastroenterologists and surgeons could examine the same patient and assign different grades, creating challenges for treatment planning and communication across specialties.
“The fundamental reason we undertook this work was simple: gastroenterologists and surgeons who treat reflux were describing the same anatomy in different ways, and we wanted one shared, standardized language to improve patient care,” Thosani said.
To address that gap, the American Foregut Society assembled a multidisciplinary working group to create a more objective and reproducible classification system.
Unlike traditional clinical studies, this project was built through expert consensus rather than patient data collection. The group convened a 13-member panel comprised of seven gastroenterologists and six gastrointestinal surgeons and used a modified Delphi process to develop the framework.
Panel members first evaluated limitations of the existing Hill grading system through structured surveys, then proposed and refined improvements over multiple rounds of discussion until consensus was reached. Bringing both specialties together was intentional and central to the effort’s goal of creating a common vocabulary for reflux care.
The resulting system introduces a standardized way to characterize the esophagogastric junction using three measurable components: length, diameter, and flap valve presence or absence.
Using centimeter-based measurements, the classification evaluates how much the opening in the diaphragm has widened and how far the stomach has shifted upward. The system categorizes the junction into four grades ranging from intact anatomy to complete disruption , while also standardizing endoscopic technique and terminology.
“This classification replaces subjective impressions with objective measurements, allowing everyone caring for a patient to speak the same language,” Thosani said.
Thosani said the approach could become increasingly important as new endoscopic therapies for reflux continue to emerge and selecting the right patients becomes more critical.
“It ultimately comes back to patients,” he said. “When clinicians describe the junction consistently, treatment decisions become more informed and more reliable.”
The team emphasized that accurate grading still depends on proper endoscopic technique, including sustained insufflation and gentle provocative maneuvers to avoid missing subtle hernias. They also noted that the framework builds on the foundational flap-valve work established by Dr. Lucius Hill.
Moving forward, the team will validate whether the classification predicts the presence and severity of gastroesophageal reflux disease and explore how it can be adapted for patients who have previously undergone anti-reflux procedures.