Controversy exists regarding the value of gross mucosal changes of the esophagus at the time of endoscopy in predicting histologic esophagitis. Accordingly, we reviewed the records of 279 pediatric patients who underwent both an upper endoscopy and simultaneous grasp esophageal biopsy. Of those patients with no gross mucosal abnormalities, 30% had evidence of esophagitis on biopsy. Similarly, there was a poor association between the presence of endoscopic findings and histologic esophagitis. We conclude that gross esophageal mucosal changes are poor predictors of histologic esophagitis and that endoscopic evaluation alone is inadequate for children and adolescents in whom esophagitis is suspected. Esophageal biopsies should be obtained in all such patients, even when no gross mucosal abnormalities are found.