What is the Los Angeles classification for distal esophagitis and the recommended management for each grade?

Los Angeles Classification for Distal Esophagitis

The Los Angeles (LA) classification is the standard grading system for GERD-related erosive esophagitis, defining four grades (A-D) based on the extent of mucosal breaks, with Grade B or higher constituting confirmatory evidence of erosive reflux disease requiring specific management strategies. 1, 2

Classification System

The LA classification grades erosive esophagitis based on mucosal breaks (defined as areas of slough or erythema with sharp demarcation from adjacent mucosa):

• Grade A: One or more mucosal breaks ≤5mm that do not extend between the tops of two mucosal folds 3
• Grade B: One or more mucosal breaks >5mm that do not extend between the tops of two mucosal folds 3
• Grade C: Mucosal breaks extending between the tops of two or more mucosal folds but involving <75% of the esophageal circumference 3
• Grade D: Mucosal breaks involving ≥75% of the esophageal circumference 3

Clinical Significance by Grade

Grade A (Borderline Disease)

• Not considered confirmatory evidence of erosive reflux disease - can be seen in healthy asymptomatic volunteers 1, 2
• Only 17.6% of patients with Grade A have objective GERD on pH monitoring 2

Grade B or Higher (Confirmed GERD)

• Constitutes conclusive objective evidence of erosive reflux disease 1, 2
• 100% of patients with Grade B or higher have objective GERD on pH monitoring 2

Grades C and D (Severe Disease)

• Represent severe erosive disease requiring either continuous long-term PPI therapy or consideration of anti-reflux intervention 2, 3
• Require follow-up endoscopy after treatment to document healing and exclude underlying malignancy or Barrett's esophagus 1, 4

Management Algorithm by Grade

Grade A Management

• Optimize PPI therapy rather than committing to lifelong daily therapy 2
• Implement aggressive lifestyle modifications including weight management 2
• Consider cognitive behavioral therapy or gut-directed hypnotherapy as adjunctive measures 2
• If symptoms remain controlled after optimization, wean to lowest effective dose and consider on-demand therapy with H2 blockers or antacids 2
• Critical pitfall: Avoid automatically committing patients to lifelong daily PPI therapy, as Grade A represents borderline disease 2
• If incomplete PPI response, perform prolonged wireless pH monitoring off PPI to determine if true pathologic acid exposure exists 2

Grade B Management

• Provide 4-8 week trial of single-dose PPI therapy 1, 3
• With inadequate response, increase to twice daily dosing or switch to more effective acid suppressive agent 1
• When adequate response achieved, taper PPI to lowest effective dose 1
• Consider anti-reflux intervention for chronic maintenance if erosive disease persists 3

Grades C and D Management

• Require continuous long-term PPI therapy or invasive anti-reflux procedures 2, 3
• Treat with double-dose PPIs (twice daily) for 8-12 weeks 4
• Mandatory follow-up endoscopy at 6 weeks after high-dose PPI therapy to exclude underlying malignancy or Barrett's esophagus 1, 4
• Take biopsy specimens to exclude underlying dysplasia 1
• Optimize lifestyle measures in addition to pharmacotherapy 3
• Consider laparoscopic fundoplication, magnetic sphincter augmentation, or transoral incisionless fundoplication in carefully selected patients 1

Endoscopic Documentation Requirements

Complete endoscopic evaluation must include 1:

• Erosive esophagitis graded according to LA classification when present
• Hill grade of diaphragmatic flap valve
• Axial hiatus hernia length
• Inspection for Barrett's esophagus with Prague classification and biopsy when present

Critical Limitations

The LA classification should NOT be used for non-GERD esophagitis including eosinophilic esophagitis, infectious esophagitis, medication-induced esophagitis, or Crohn's disease-related esophagitis 2. For eosinophilic esophagitis, use the Eosinophilic Esophagitis Endoscopic Reference System (EREFS) or Index for Severity of Eosinophilic Esophagitis (I-SEE) score instead 2.

Common Pitfalls

• Grade A has poor interobserver agreement and may not reliably distinguish from normal findings 5
• Endoscopists frequently fail to communicate the LA grade to pathologists when biopsies are obtained 6
• Standard white-light endoscopy may miss mucosal breaks; chromoendoscopy with Lugol's solution significantly improves detection and reduces misclassification 7
• The modified LA classification used in Japan (adding grades M and N for minimal changes) has poor interobserver agreement and is not recommended in Western guidelines 5, 8