The American Foregut Society endoscopic classification outperforms Hill in phenotyping the esophago-gastric junction to guide gastroesophageal reflux disease management

Gastroesophageal reflux disease (GERD) is driven by anti-reflux barrier (ARB) disruption, requiring precise endoscopic tools to guide diagnosis and management. The Hill classification, based solely on flap valve (FV), lacks precision. The American Foregut Society (AFS) classification, integrating hiatal hernia length (L), hiatal opening diameter (D), and FV (F), offers a comprehensive approach to phenotype esophago-gastric junction (EGJ) dysfunction. This study aims to assess the superiority of the AFS classification over the Hill and to weight the single AFS components contribution. A retrospective analysis of adult patients evaluated with upper-GI endoscopy (EGD), high-resolution manometry, and reflux monitoring study for GERD symptoms at our Institution (2022-2025) was performed. GERD was defined by Lyon 2.0 criteria. EGJ was graded using AFS and Hill classifications. GERD prevalence was compared across AFS and Hill grades and by the number of disrupted AFS components. Logistic regression assessed individual AFS component contributions. Of 249 patients (median age 52 years, 47% male, BMI 23.9 kg/m2), 127 had GERD. At least one AFS component was disrupted in 71.9% of the patients. GERD prevalence differed significantly across AFS grades 1-2 vs. 3 and 3 vs. 4, unlike Hill grades, where 2 and 3 overlapped. Patients with 1 and 2 impaired components were significantly different from those with 3 and 4. Pathologic D (OR = 2.537) and F (OR = 3.336) were independent GERD predictors. ROC analysis confirmed AFS superiority over Hill (AUC 0.750 vs. 0.653, P < 0.001). The AFS classification enhances EGD diagnostic yield, outperforming Hill in EGJ phenotyping. The AFS improves patient stratification for pathophysiological testing and tailored therapies, offering a practical tool for GERD management.