From the Guidelines
The Los Angeles (LA) Classification system is the most widely used and recommended scoring system for grading esophageal mucosal damage in GERD during endoscopy, as recently supported by the 2022 AGA clinical practice update 1. This system categorizes esophagitis into four grades (A through D) based on the extent and severity of mucosal breaks.
- Grade A indicates one or more mucosal breaks confined to mucosal folds and less than 5mm in length.
- Grade B describes one or more mucosal breaks greater than 5mm in length but not continuous between the tops of two mucosal folds.
- Grade C represents mucosal breaks that are continuous between the tops of two or more mucosal folds but involve less than 75% of the esophageal circumference.
- Grade D, the most severe, indicates mucosal breaks involving at least 75% of the esophageal circumference. The LA system is valuable because it focuses on actual mucosal breaks rather than non-specific findings like erythema, which can be subjective. Proper documentation using this system helps determine appropriate treatment intensity and duration, with more severe grades often requiring more aggressive acid suppression therapy, as noted in the context of managing severe erosive esophagitis 1. The use of the LA Classification system is also emphasized in the management of Barrett’s esophagus, particularly in the context of low-grade dysplasia, where accurate assessment and documentation of esophageal mucosal changes are critical for guiding treatment decisions and surveillance strategies 1. Therefore, the LA Classification system should be used as the standard for grading esophageal mucosal damage in GERD during endoscopy, given its widespread acceptance, clinical utility, and support from recent clinical practice updates 1.
From the Research
Scoring Systems for GERD Based on Endoscopy
The scoring systems used to grade esophageal mucosal damage in Gastroesophageal Reflux Disease (GERD) during endoscopy include:
- The Los Angeles (LA) classification system, which grades the severity of erosive esophagitis from A (minimal) to D (very severe) based on the extent of endoscopically visible mucosal breaks 2, 3, 4
- The Savary-Miller endoscopic classification system, which is used widely but has variable usage and interpretation 3
- The "MUSE" (metaplasia, ulceration, stricturing, and erosions) classification, which provides clear definitions of the relevant endoscopic features and is based on a standardized report form 3
Key Features of the Los Angeles Classification System
The Los Angeles classification system is commonly used to grade the severity of erosive esophagitis in GERD patients. The key features of this system include:
- Grade A: minimal erosive esophagitis
- Grade B: moderate erosive esophagitis
- Grade C: severe erosive esophagitis with transverse mucosal breaks
- Grade D: very severe erosive esophagitis with extensive mucosal damage 2, 4
Importance of Accurate Grading
Accurate grading of EE severity is crucial in clinical trials of medical EE treatments, as EE severity strongly influences both initial rates of healing and the likelihood of recurrence during maintenance treatment 2. The Los Angeles classification system has been shown to be reliable and reproducible, especially when used by experienced endoscopists 5.
Limitations and Variations
However, there are limitations and variations in the use of these scoring systems. For example, the Savary-Miller classification system has variable usage and interpretation 3, and the Los Angeles classification system may not record the presence or severity of other GERD lesions 3. Additionally, endoscopy is not universally applicable, and 40 to 60 percent of patients with typical reflux symptoms do not have esophageal erosions and are considered to have "endoscopy negative reflux disease" (ENRD) 3.