Los Angeles (LA) Grade 2 Esophagitis: Classification and Clinical Significance
LA Grade 2 (also known as LA Grade B) esophagitis indicates moderate reflux-related mucosal damage with at least one mucosal break greater than 5mm in length that does not extend between the tops of two mucosal folds. This classification is part of the standardized Los Angeles Classification system used to grade the severity of erosive esophagitis during endoscopic evaluation 1.
The Los Angeles Classification System
The LA classification grades esophagitis from A to D based on the extent and severity of mucosal breaks:
- Grade A: One or more mucosal breaks ≤5mm in length that do not extend between the tops of two mucosal folds
- Grade B (Grade 2): One or more mucosal breaks >5mm in length that do not extend between the tops of two mucosal folds
- Grade C: Mucosal breaks that extend between the tops of two or more mucosal folds but involve less than 75% of the esophageal circumference
- Grade D: Mucosal breaks that involve at least 75% of the esophageal circumference
Clinical Significance of LA Grade 2/B Esophagitis
LA Grade B esophagitis has important clinical implications:
- It represents definitive evidence of GERD 1
- It indicates moderate severity of reflux disease
- Patients with LA Grade B or higher esophagitis should be optimized on PPI therapy 1
- Unlike LA Grade A (which can sometimes be seen in asymptomatic individuals), Grade B is considered clinically significant erosive disease 1
Treatment Implications
The severity grade directly impacts treatment decisions:
- LA Grade B esophagitis is considered clinically significant and warrants PPI therapy optimization 1
- Patients with LA Grade B esophagitis should receive:
- Optimized PPI dosing to control symptoms
- Aggressive lifestyle modifications
- Weight management if applicable
- Consideration of cognitive behavioral therapy or neuromodulators as adjuncts 1
Unlike higher grades (C and D), which require indefinite PPI therapy, patients with Grade B who have no erosive disease at baseline after treatment may be weaned to the lowest effective dose or switched to on-demand therapy with H2 blockers/antacids 1.
Prognosis and Monitoring
The grade of esophagitis has prognostic value:
- Patients with LA Grade B esophagitis have better healing rates with PPI therapy compared to those with more severe grades 2
- In one study, patients with Grade 2 esophagitis showed healing rates of 87% with omeprazole 20mg daily and 97% with 40mg daily after 4 weeks 2
- However, relapse rates are high (approximately 82% within 6 months) when treatment is discontinued 2
Important Clinical Considerations
- LA Grade B esophagitis is considered conclusive evidence of GERD and does not require additional pH testing to confirm the diagnosis 1
- The location of mucosal breaks differs by grade - Grade A and B lesions typically appear in the right-anterior wall of the lower esophagus, while Grade C lesions tend to be transverse and in the posterior wall 3
- The presence of LA Grade B esophagitis warrants consideration for long-term PPI therapy, though the dose should be optimized to the lowest effective level 1
Pitfalls to Avoid
- Don't confuse LA Grade A with Grade B - Grade A lesions are smaller (≤5mm) and may not always represent pathological GERD
- Don't assume all patients with Grade B esophagitis need indefinite full-dose PPI therapy - attempt to find the lowest effective dose after healing
- Don't rely on non-erosive changes like erythema for diagnosis - the LA classification specifically focuses on mucosal breaks with clear demarcation 4
- Don't forget to evaluate for complications such as Barrett's esophagus, which may require surveillance regardless of healing of erosive disease
Remember that the LA classification focuses specifically on erosive changes and doesn't account for other GERD complications like strictures or Barrett's esophagus, which should be documented separately 4.