Essential Endoscopy Suite Classification Systems for GERD Assessment
Core Classification Systems to Display
For optimal GERD evaluation during endoscopy, display the Los Angeles Classification for erosive esophagitis, Prague Classification for Barrett's esophagus, and Hill Grade Classification for the gastroesophageal flap valve. 1
1. Los Angeles (LA) Classification for Erosive Esophagitis
This is the primary system for grading reflux-related mucosal injury 1, 2:
Grade Definitions:
Grade A: One or more mucosal breaks ≤5 mm in length, not extending between the tops of two mucosal folds 2, 3
Grade B: One or more mucosal breaks >5 mm long, not extending between the tops of two mucosal folds 2, 3
Grade C: Mucosal breaks continuous between the tops of ≥2 mucosal folds, involving <75% of esophageal circumference 2, 3
- Clinical significance: Severe erosive disease requiring definitive PPI therapy 1
Grade D: Mucosal breaks involving ≥75% of esophageal circumference 2, 3
- Clinical significance: Severe erosive disease; may indicate severe GERD phenotype 1
Critical Clinical Distinction:
Only LA Grade B or higher constitutes confirmatory evidence of erosive reflux disease 1, 4. Grade A is considered "borderline GERD" and requires pH monitoring off PPI for definitive diagnosis 1, 4.
2. Prague Classification for Barrett's Esophagus
Document Barrett's esophagus using the Prague C&M criteria 1:
- C (Circumferential extent): Length of circumferential Barrett's mucosa above the gastroesophageal junction (in cm) 1
- M (Maximum extent): Maximum length of Barrett's mucosa including tongues (in cm) 1
Clinical Significance:
- Long-segment Barrett's esophagus (≥3 cm) constitutes confirmatory evidence of GERD and does NOT require additional pH monitoring 1
- Biopsy is mandatory when Barrett's esophagus is identified 1
3. Hill Grade Classification for Gastroesophageal Flap Valve
Assess the integrity of the anti-reflux barrier during retroflexed view 1:
- Grade I: Prominent fold of tissue closely approximates the endoscope with minimal air insufflation
- Grade II: Less prominent fold, opens and closes around the endoscope
- Grade III: Ridge present but does not close around the endoscope
- Grade IV: No fold present; gaping hiatus
Clinical Application:
Document Hill grade as part of complete GERD endoscopic evaluation, particularly when considering anti-reflux procedures 1.
4. Additional Documentation Requirements
Hiatal Hernia Measurement:
- Measure and document axial hiatus hernia length in centimeters 1
- Large hiatal hernias may indicate severe GERD phenotype and influence surgical candidacy 1
Squamocolumnar Junction:
- Clearly identify and photograph the squamocolumnar junction 1
- This landmark is critical for pH probe placement (6 cm proximal) if wireless monitoring is performed 1
5. Optional Classification Systems
Forrest Classification (for bleeding peptic ulcers):
Display if your endoscopy suite also evaluates upper GI bleeding 1
Paris Classification (for superficial neoplastic lesions):
Display if performing surveillance for dysplasia or early gastric cancer 1
Common Pitfalls to Avoid
- Do not over-interpret LA Grade A esophagitis as definitive GERD; it requires pH monitoring for confirmation 1, 4
- Erythema alone is NOT diagnostic of GERD and should be ignored based on current evidence 2
- Document all components: LA grade, Hill grade, hiatal hernia length, and Barrett's extent for complete evaluation 1
- Ensure adequate insufflation and mucosal cleansing before grading esophagitis severity, as inadequate visualization leads to misclassification 1, 3
- Photograph the gastroesophageal junction in both antegrade and retroflexed views to capture all relevant anatomic features 1