Gastroscopy reports sometimes contain phrases such as “lax cardia”, “lax gastro-oesophageal junction”, “patulous cardia” or “lax lower oesophageal sphincter”.
These phrases are generally used to describe an antireflux barrier between the oesophagus and the stomach that does not look tight enough at endoscopy.
This finding is not cancer. Nor does it on its own make a diagnosis of reflux disease.
What is the gastro-oesophageal junction?
The region where the oesophagus joins the stomach is called the gastro-oesophageal junction.
There is no single “valve” preventing reflux here. The protective mechanism is formed by several structures working together: the lower oesophageal sphincter (LES), the crural fibres of the diaphragm, the anatomy of the gastro-oesophageal junction and the angle of His.
This is why the phrase patients often use — “my stomach valve has loosened” — is a simplification.
Does a lax cardia cause reflux?
It can make reflux easier.
If the antireflux barrier is not effective enough, stomach contents can more easily flow back into the oesophagus. This can lead to heartburn, a bitter or sour taste in the mouth, belching and burning or discomfort behind the breastbone.
But a lax cardia does not equal definite reflux disease.
Some people have a lax appearance at endoscopy without any significant reflux symptoms. Conversely, reflux disease can be present in someone whose endoscopy looks normal.
Is it the same as a hiatal hernia?
No.
A hiatal hernia is the movement of part of the stomach upwards through the opening in the diaphragm. A lax gastro-oesophageal junction is a description of the endoscopic appearance of the antireflux barrier.
The two can be present together, and when they are they can make reflux easier.
What do Hill Grade I–II–III–IV mean?
During a gastroscopy, looking back from inside the stomach, the flap valve formed by the gastro-oesophageal junction can be assessed using the Hill classification. Roughly:
- Hill Grade I A well-defined, tight antireflux flap valve.
- Hill Grade II Mild laxity.
- Hill Grade III Marked laxity.
- Hill Grade IV A markedly open junction, often together with a hiatal hernia.
As the grade rises, the endoscopic appearance of the antireflux barrier at the gastro-oesophageal junction deteriorates.
Hill Grade III–IV are not cancer stages.
Does seeing a lax cardia prove there is reflux?
Not on its own.
In assessing reflux disease, symptoms + endoscopic findings + reflux testing where needed are weighed together.
Where findings such as LA Grade B–D oesophagitis, Barrett’s oesophagus or a peptic stricture are present at endoscopy, stronger evidence for reflux is obtained. In some patients where the diagnosis is uncertain, 24-hour pH or pH-impedance measurement may be needed.
Is treatment needed?
Treatment should not be started simply because a report says “lax cardia”.
Treatment is planned according to the patient’s symptoms and whether reflux disease is present. If there is reflux, losing weight where there is excess weight, avoiding eating before lying down, adjusting the foods and habits that increase reflux for that person, and acid-suppressing medicines where needed may be used.
In selected patients with objectively demonstrated reflux, endoscopic or surgical antireflux treatments may come into consideration. Not every lax cardia needs an operation.
Is a follow-up endoscopy needed?
Regular follow-up endoscopy is generally not needed for a lax cardia alone.
The need for follow-up is determined by the grade of any oesophagitis, Barrett’s oesophagus, a hiatal hernia and the other endoscopic findings.
Which symptoms need separate assessment?
Assessment should not be delayed if reflux symptoms are accompanied by
Difficulty swallowing · food sticking · vomiting blood · black stools · unexplained anaemia · persistent vomiting · unintended weight loss.
Remember
- A lax cardia Is not cancer.
- It can make reflux easier But it does not on its own make a diagnosis of reflux.
- A hiatal hernia Is not the same thing as a lax cardia.
- I–II–III–IV Are not cancer stages but grades of the endoscopic appearance of the gastro-oesophageal flap valve.
- Treatment Is decided from the patient’s symptoms and objective findings of reflux, not from a single phrase on an endoscopy report.
This is not enough to make a diagnosis
“The gastro-oesophageal junction is lax” or “the cardia is lax” is not on its own a diagnosis. It has to be weighed together with the patient’s symptoms, endoscopic findings such as oesophagitis and hiatal hernia, and reflux testing where needed.
Sources
- Prof. Ali Tüzün İnce, MD