How is the severity of Gastroesophageal Reflux Disease (GERD) graded and what are the treatment options based on severity?

GERD Severity Grading

GERD severity is graded using the Los Angeles (LA) Classification system for erosive esophagitis (Grades A-D), combined with acid exposure time (AET) measurements from prolonged pH monitoring, with severe GERD defined by LA Grade C/D esophagitis, AET >12.0%, bipositional reflux, or DeMeester score >50. 1

Endoscopic Severity Classification

The Los Angeles Classification is the primary grading system for reflux-related mucosal injury: 2

• Grade A (Borderline GERD): One or more mucosal breaks ≤5mm that do not extend between the tops of two mucosal folds. This is considered borderline GERD and does not constitute definitive evidence of GERD. 2

• Grade B (Confirmed GERD): One or more mucosal breaks >5mm that do not extend between the tops of two mucosal folds. This grade or higher constitutes confirmatory evidence of erosive reflux disease. 1, 2

• Grade C (Severe GERD): Mucosal breaks that extend between the tops of two or more mucosal folds but involve <75% of the esophageal circumference. This indicates severe GERD phenotype requiring long-term PPI therapy or anti-reflux procedures. 1

• Grade D (Very Severe GERD): Mucosal breaks involving ≥75% of the esophageal circumference. This represents the most severe erosive disease requiring continuous long-term PPI therapy or invasive anti-reflux procedures. 1

Physiologic Severity Assessment

Acid exposure time (AET) from prolonged wireless pH monitoring off PPI therapy provides objective severity grading: 1

• No GERD: AET <4.0% on all days of monitoring 1
• Borderline GERD: AET ≥4.0% on at least one day but not meeting criteria for conclusive GERD 1
• Confirmed GERD: AET ≥6.0% on 2 or more days 1
• Severe GERD phenotype: AET >12.0%, bipositional reflux, or DeMeester score ≥50 1

Symptom-Based Severity

Moderate symptoms occurring ≥2 days per week significantly impair quality of life and define clinically relevant GERD. 1 Over 90% of patients accept up to one day of mild heartburn during treatment, but this falls to 32% when experiencing mild heartburn 2-4 days per week. 1

Treatment Algorithm Based on Severity

Mild GERD (No erosive disease or LA Grade A)

• Initial approach: 4-8 week trial of single-dose PPI therapy 1
• If controlled: Wean to lowest effective dose or on-demand therapy with H2 blockers/antacids 1
• Adjunctive therapy: Aggressive lifestyle modifications and weight management 1

Moderate GERD (LA Grade B)

• Primary treatment: Optimize PPI to control symptoms 1
• If erosive disease at baseline: Continue PPI indefinitely and consider anti-reflux intervention for chronic maintenance 1
• Uncontrolled symptoms: Esophageal physiologic testing (high-resolution manometry, esophagram) to assess candidacy for anti-reflux procedures 1

Severe GERD (LA Grade C/D, AET >12.0%, or DeMeester >50)

• Required treatment: Continuous long-term PPI therapy or invasive anti-reflux procedures 1
• Mandatory interventions: Optimization of lifestyle measures in addition to pharmacotherapy 1
• Surgical consideration: Laparoscopic fundoplication, magnetic sphincter augmentation, or transoral incisionless fundoplication in carefully selected patients 1
• For obese patients: Roux-en-Y gastric bypass is an effective primary anti-reflux intervention 1

Additional Severity Indicators

Complete endoscopic evaluation must document: 1, 2

• Hill Grade Classification of the gastroesophageal flap valve (Grade I-IV) 2
• Axial hiatal hernia length in centimeters (large hernias indicate severe phenotype) 2
• Prague Classification for Barrett's esophagus (long-segment ≥3cm constitutes confirmatory GERD evidence) 2

Critical Pitfalls

Common grading errors include: 3

• Misclassifying LA Grade A as definitive GERD rather than borderline disease 2
• Inadequate mucosal visualization leading to undergrading of esophagitis severity 2
• Failing to perform prolonged pH monitoring in patients without LA Grade B or higher esophagitis 1
• Assuming small hiatal hernias (<3cm) indicate severe GERD phenotype 2

Before considering anti-reflux procedures, candidacy assessment must include: 1

• Confirmatory evidence of pathologic GERD
• Exclusion of achalasia
• Assessment of esophageal peristaltic function