What is Grade A erosive esophagitis?

Grade A Erosive Esophagitis

Grade A erosive esophagitis represents the mildest form of GERD-related mucosal injury in the Los Angeles classification system, characterized by one or more mucosal breaks ≤5 mm in length that do not extend between the tops of two mucosal folds. 1

Clinical Significance and Diagnostic Uncertainty

Grade A esophagitis is NOT considered definitive evidence of GERD because it can be found in healthy asymptomatic volunteers and lacks the specificity of higher grades. 1 Key diagnostic considerations include:

• Only 17.6% of patients with LA Grade A have objective GERD confirmed on pH monitoring, compared to 100% of patients with Grade B or higher 1
• Grade A findings should be interpreted as "borderline GERD" rather than conclusive erosive reflux disease 2
• The American College of Gastroenterology considers only LA Grade B or higher as confirmatory evidence of erosive reflux disease 1

The Los Angeles Classification System

The LA classification applies exclusively to GERD-related erosive esophagitis and should not be used for other causes of esophageal inflammation such as eosinophilic esophagitis, infectious esophagitis, medication-induced injury, or Crohn's disease. 3, 1 The system defines a "mucosal break" as an area of slough or erythema with sharp demarcation from adjacent normal mucosa. 4

The four grades are:

• Grade A: One or more mucosal breaks ≤5 mm, not extending between mucosal fold tops 1
• Grade B: At least one mucosal break >5 mm, not extending between mucosal fold tops 1
• Grade C: Mucosal breaks extending between ≥2 mucosal folds, involving <75% of esophageal circumference 1
• Grade D: Mucosal breaks involving ≥75% of esophageal circumference 1

Management Approach for Grade A Esophagitis

Patients with Grade A esophagitis require a personalized approach that differs substantially from higher grades:

Initial Treatment Strategy

• Optimize PPI therapy to control symptoms rather than assuming lifelong daily therapy is mandatory 2
• Implement aggressive lifestyle modifications including weight management 2
• Consider cognitive behavioral therapy or gut-directed hypnotherapy as adjunctive measures 2

Maintenance Therapy Considerations

• If symptoms remain controlled after optimization, wean to the lowest effective dose and consider on-demand therapy with H2 blockers or antacids 2
• This contrasts sharply with Grade C/D esophagitis, where continuous daily PPI therapy is mandatory 5, 1

Diagnostic Confirmation

If Grade A esophagitis is found with incomplete PPI response, consider prolonged wireless pH monitoring off PPI therapy to determine if true pathologic acid exposure exists (AET ≥4.0% but not meeting criteria for conclusive GERD). 2

Critical Pitfall to Avoid

Do not automatically commit patients with Grade A findings to lifelong daily PPI therapy. 2 Unlike Grade B-D esophagitis where continuous PPI is essential, Grade A represents borderline disease that may respond to less aggressive acid suppression combined with lifestyle modification. The management goal is symptom control with the minimal effective intervention, not necessarily complete acid suppression. 2