Is the AFS (Acid Flux Score) classification widely accepted and used in managing Gastroesophageal Reflux Disease (GERD) for guiding treatment decisions?

AFS Classification: Limited Adoption in GERD Management

The AFS (American Foregut Society) classification for esophagogastric junction integrity is NOT widely used or accepted in standard GERD management, and current major guidelines do not recommend it for routine clinical decision-making. 1

What Guidelines Actually Recommend

The Los Angeles classification remains the established standard for grading erosive esophagitis in GERD evaluation, explicitly recommended by the American Gastroenterological Association in their 2022 guidelines. 1, 2

Standard Endoscopic Assessment Includes:

• Erosive esophagitis graded by Los Angeles classification (when present) 1
• Hill grade of the esophagogastric flap valve 1
• Axial hiatus hernia length measurement 1
• Barrett's esophagus assessment using Prague classification (with biopsy when present) 1

Why AFS Classification Has Limited Acceptance

Lack of Guideline Support

The 2022 AGA Clinical Practice Update—the most recent and authoritative GERD guideline—makes no mention of the AFS classification system despite providing comprehensive recommendations for endoscopic evaluation. 1

Limited Validation Data

The only recent study examining AFS classification (2025) found merely a weak positive correlation between AFS grades and GERD symptoms (r = 0.201 for GERD-HRQL, r = 0.203 for heartburn). 3 While esophagitis rates increased with higher AFS grades, this study:

• Was limited to bariatric surgery candidates 3
• Acknowledged need for "further validation studies with pH testing" 3
• Did not demonstrate superiority over established classifications 3

What Actually Guides GERD Management Decisions

For Diagnostic Evaluation:

• Acid exposure time (AET) via prolonged wireless pH monitoring (96-hour preferred) is the key physiomarker for phenotyping GERD 1
• Los Angeles Grade B or higher esophagitis constitutes confirmatory evidence of erosive reflux disease 1, 2
• AET ≥6.0% on ≥2 days of wireless monitoring confirms pathologic GERD 1

For Treatment Decisions:

Severe GERD phenotype requiring long-term PPI or anti-reflux intervention is defined by: 1

• Los Angeles Grade C or D esophagitis
• AET >12.0% or DeMeester Score ≥50
• Bipositional reflux pattern
• Large hiatal hernia

Borderline GERD (Los Angeles A or elevated AET not meeting full criteria) can be managed with lowest effective PPI dose or on-demand therapy. 1, 2

Critical Pitfall to Avoid

Do not adopt unvalidated classification systems when established, guideline-endorsed tools exist. The Los Angeles classification has decades of validation, reproducibility data, and integration into treatment algorithms. 2, 4 The AFS classification, while potentially useful in specific research contexts (particularly bariatric surgery), lacks the evidence base and professional society endorsement necessary for routine clinical adoption. 3

Practical Algorithm for Endoscopic GERD Assessment:

1. Grade erosive esophagitis using Los Angeles classification (A, B, C, D) 1, 2
2. Measure hiatal hernia length (if present) 1
3. Assess Hill grade of gastroesophageal flap valve 1
4. Evaluate for Barrett's esophagus using Prague classification 1
5. Combine endoscopic findings with pH monitoring data (AET, reflux pattern) to phenotype disease severity 1

This approach is evidence-based, guideline-endorsed, and directly informs management decisions regarding PPI optimization, need for anti-reflux procedures, and long-term surveillance strategies. 1