High-Resolution Manometry Assessment of Esophagitis Across Los Angeles Grades Validates Lyon 2.0 Criteria

Introduction: Gastroesophageal reflux disease (GERD) with erosive esophagitis is driven by antireflux barrier (ARB) dysfunction, yet a comprehensive high-resolution manometry (HRM) assessment across Los Angeles (LA) grades is lacking. This study evaluates HRM metrics in patients with erosive esophagitis to validate Lyon 2.0 consensus criteria, hypothesizing that LA grade B esophagitis shares manometric features with severe GERD (LA grades C-D) and that HRM can stratify LA grade A patients for objective GERD risk. Methods: A retrospective multicenter study (July 2022 to July 2025) enrolled 254 patients with GERD symptoms and erosive esophagitis (LA grade A: 145, B: 84, C-D: 25) across 6 centers. Patients underwent off-PPI endoscopy, HRM, and pH monitoring. HRM assessed esophagogastric junction (EGJ) morphology, EGJ-contractile integral (EGJ-CI), ineffective esophageal motility (IEM), straight leg raise (SLR), and Milan Score. Pathologic GERD was defined per Lyon 2.0 criteria. Results: LA grades B and C-D showed a higher rate of hiatal hernia, positive SLR, and lower EGJ-CI compared with LA grade A ( P <0.001). Milan Score increased with esophagitis severity ( P <0.001). Reflux monitoring confirmed pathologic GERD in 96% (B) and 100% (C-D) versus 50% (A) based on pH and impedance criteria. In LA grade A, patients with ≥2 disrupted ARB mechanisms (67.5%) had higher GERD rates than those with intact ARB (29.2%). Discussion: HRM supports Lyon 2.0 inclusion of LA grade B as definitive GERD, with manometric profiles similar to C-D. In LA grade A, compromised ARB identifies higher GERD risk, guiding therapy escalation.