Can the Los Angeles (LA) classification be used for esophagitis caused by factors other than Gastroesophageal Reflux Disease (GERD)?

Los Angeles Classification for Non-GERD Esophagitis

The Los Angeles (LA) classification system is specifically designed for erosive esophagitis caused by GERD and should not be used to classify esophagitis from other etiologies such as eosinophilic esophagitis, infectious esophagitis, or medication-induced esophagitis. 1

Why LA Classification is GERD-Specific

The LA classification was developed and validated exclusively for grading the severity of acid-related erosive esophagitis in the context of gastroesophageal reflux disease:

• LA grades B, C, and D erosive esophagitis are considered highly specific for GERD and represent objective evidence of acid-mediated mucosal injury 1
• The classification system guides GERD-specific management decisions, including whether patients require long-term PPI therapy (LA grade C/D should generally not discontinue PPIs) 1
• LA classification severity correlates with GERD complications such as stricture formation, bleeding risk, and Barrett's esophagus development 1

Alternative Classification Systems for Non-GERD Esophagitis

When encountering esophagitis from other causes, use etiology-specific classification systems rather than forcing the LA classification:

For Eosinophilic Esophagitis:

• Use the Eosinophilic Esophagitis Endoscopic Reference System (EREFS) to document endoscopic features including rings, exudates, furrows, edema, and strictures 1
• The newer Index for Severity of Eosinophilic Esophagitis (I-SEE) score incorporates endoscopic features and is anticipated to become the standard for assessing disease activity 1
• EoE diagnosis requires ≥15 eosinophils per high-power field on biopsy, not endoscopic appearance alone 1, 2

Key Distinguishing Features from GERD:

• EoE typically involves long segments or the proximal esophagus, whereas GERD predominantly affects the distal esophagus 3
• Endoscopic findings in EoE include fixed rings (trachealization), white exudates, longitudinal furrows, and mucosal fragility—features not captured by LA classification 1
• Clinical features that distinguish EoE from GERD include: younger age, dysphagia, food impaction history, documented food allergies, absence of hiatal hernia, and presence of eosinophil degranulation on biopsy 4, 5

Critical Clinical Pitfall

A common diagnostic error is assuming that any esophageal inflammation can be graded using LA classification. This leads to:

• Misclassification of eosinophilic esophagitis as "mild GERD" when white plaques or furrows are present
• Inappropriate PPI therapy as sole treatment when alternative diagnoses require different management 1
• Failure to obtain adequate biopsies from proximal and distal esophagus to diagnose EoE (which can be patchy or focal) 1, 3

Before applying LA classification, you must first exclude non-GERD causes of esophagitis including eosinophilic esophagitis, infectious esophagitis (fungal, viral), medication-induced injury, and Crohn's disease 1, 3

Practical Diagnostic Algorithm

When encountering esophagitis on endoscopy:

1. Document the pattern and location: Distal-predominant erosions suggest GERD; proximal involvement, rings, or furrows suggest EoE 3, 4
2. Obtain biopsies from both proximal and distal esophagus regardless of endoscopic appearance, as EoE can be patchy 1
3. If eosinophils are present: Distinguish PPI-responsive esophageal eosinophilia from true EoE by clinical judgment and therapeutic response 1
4. Only apply LA classification if: Erosive changes are present, distal esophagus is primarily involved, and biopsies confirm acid-related injury without significant eosinophilia 1