When a gastroscopy report says “LA Grade A, B, C or D oesophagitis”, it describes the endoscopic severity of the erosions that reflux has caused in the oesophagus.
The letters A, B, C and D here are not cancer stages. From A to D the extent of the mucosal damage in the oesophagus increases.
What is the Los Angeles classification?
The Los Angeles (LA) classification is a standard system used to grade erosive oesophagitis due to reflux at gastroscopy.
The endoscopist looks at the length of the mucosal breaks (erosions) in the oesophagus and how far they extend around its circumference.
- LA Grade A There are one or more mucosal breaks. Each is 5 mm or shorter and does not extend between the tops of two mucosal folds. This is the mildest grade of the classification.
- LA Grade B At least one mucosal break is longer than 5 mm, but it is not continuous between the tops of two adjacent mucosal folds. There is more marked erosive damage than in Grade A.
- LA Grade C Mucosal breaks are continuous between the tops of two or more mucosal folds, but involve less than 75% of the circumference of the oesophagus. This grade shows more advanced reflux oesophagitis.
- LA Grade D The mucosal damage involves 75% or more of the circumference of the oesophagus. This is the most advanced grade in the Los Angeles classification.
How can it be remembered, briefly?
| Grade | Endoscopic appearance |
|---|---|
| A | A small mucosal break of ≤5 mm |
| B | A break longer than 5 mm, but not merging between folds |
| C | Damage continuing between folds, involving <75% of the circumference |
| D | Damage involving ≥75% of the circumference of the oesophagus |
Does Grade C or D mean cancer?
No. Not even LA Grade D is a cancer stage. These letters show only the grade of erosive mucosal damage due to reflux.
But Grades C and D suggest more serious reflux disease, and are assessed differently from Grades A and B in terms of treatment and follow-up.
Is it the same as Barrett’s oesophagus?
No.
Oesophagitis describes inflammation and erosive damage in the oesophagus; Barrett’s oesophagus describes a change in the cells of the lower oesophagus associated with long-standing reflux.
Severe oesophagitis can sometimes make Barrett’s mucosa beneath it harder to see. This is why a follow-up endoscopy may be needed after severe oesophagitis has been treated.
Does treatment vary with the grade?
Yes.
Treatment mostly uses acid-suppressing medicines of the proton pump inhibitor (PPI) group. Losing weight where there is excess weight, not eating shortly before lying down and correcting the personal factors that increase reflux also matter.
In LA Grade C and D patients in particular, stronger or longer acid suppression and long-term treatment may come into consideration.
Is a follow-up endoscopy needed?
LA Grade A-B: A routine follow-up gastroscopy is not needed in every patient.
LA Grade C-D: A follow-up gastroscopy is generally important after treatment, to see that healing has occurred and to assess for Barrett’s oesophagus that may have been missed because of the severe inflammation at the outset.
Which symptoms need separate assessment?
Oesophagitis with any of these should not be brushed aside as “just my reflux”
Difficulty swallowing · food sticking · pain on swallowing · vomiting blood · black, tarry stools · unexplained anaemia · unintended weight loss · persistent vomiting.
Remember
- Grade A The mildest erosive oesophagitis.
- Grade B Longer but still limited erosions.
- Grade C Merging erosions involving less than 75% of the circumference.
- Grade D Widespread erosive damage involving 75% or more of the circumference.
- A → B → C → D The extent of the damage increases.
- A–B–C–D Are not cancer stages.
This is not enough to make a diagnosis
The Los Angeles grade has to be weighed together with the patient’s symptoms, the presence of a hiatal hernia, their risk of Barrett’s oesophagus and the other endoscopic findings. In patients found to have LA Grade C-D oesophagitis in particular, deciding on appropriate treatment and a plan for follow-up afterwards matters.
Sources
- Prof. Ali Tüzün İnce, MD