Does the American Foregut Society Endoscopic Classification of Esophago-gastric Junction Integrity Predict Acid Reflux and Esophago-gastric Junction Disruption?

Background: Gastroesophageal reflux disease (GERD) is usually associated with disruption of the esophagogastric junction (EGJ). The endoscopic Hill classification has proven to be inadequate to assess EGJ integrity. Recently, the American Foregut Society (AFS) developed an endoscopic classification focused on hiatal hernia (L), hiatal opening (D), and the flap valve (F). While pH-monitoring remains the gold standard for the diagnosis of GERD, high-resolution manometry (HRM) can assess EGJ anatomy and competency. Aim of this study is to validate the AFS classification in patients with suspected GERD assessing its accuracy in predicting EGJ disruption and pathologic reflux. Methods: We prospectively enrolled patients with suspected GERD who underwent upper endoscopy, HRM and pH-study between November 2022 and March 2023. Demographic and clinical data were analyzed. The efficacy of the AFS classification in predicting GERD (acid exposure time, AET > 6%) was assessed. Each component of the classification was compared with the corresponding HRM variable. Results: Among 56 patients (48% men, BMI 23.5 kg/m 2 , age 43 years), an AET > 6% was found in 22 (39%), and in 0% of patients with AFS grade I, 5.9% with grade II, 52% with grade III and 77.8% with grade IV ( P < .001). The L component effectively predicted the EGJ type, the D the EGJ-Contractile Integral, while the absence of the flap valve was related to a positive Straight Leg Raise maneuver. Conclusions: The new grading system is able to stratify patients with pathologic GERD. Moreover, the single components of the AFS classification are associated with manometric markers of EGJ disruption.