Grading the Severity of Ulcerative Colitis: Assessing Disease Activity and Mucosal Healing

Grading the Severity of Ulcerative Colitis: Assessing Disease Activity and Mucosal Healing

How the Ulcerative Colitis is Graded and Assessed

Ulcerative colitis (UC) is a complex and challenging inflammatory bowel disease affecting millions of individuals worldwide. This condition’s severity can vary significantly, and its impact on a patient’s life can be substantial. To effectively manage UC and determine the appropriate treatment, healthcare professionals use grading systems to assess disease activity. In this article, we will explore how the severity of UC is graded, with a specific focus on the Proposed American College of Gastroenterology Ulcerative Colitis Activity Index. We will also discuss the importance of mucosal healing within this context.


Understanding the Proposed American College of Gastroenterology Ulcerative Colitis Activity Index

The Proposed American College of Gastroenterology Ulcerative Colitis Activity Index is a comprehensive tool designed to assess the activity and severity of UC in patients. This index takes into account various clinical and laboratory parameters, allowing healthcare providers to classify the disease into one of four categories: remission, mild, moderate to severe, or fulminant. Each parameter within this index helps to determine the severity of the disease:


What is Being Graded? 

1. **Stools per day:** This criterion evaluates the number of bowel movements a patient experiences in a day. In the remission category, patients typically have formed stools. In contrast, those with more severe disease may experience over six or more loose bowel movements daily.


2. **Blood in stools:** Blood in stools is a hallmark symptom of UC. It can range from being intermittent or occasional to frequent or continuous. Patients in remission usually do not have blood in their stools.


3. **Urgency:** Urgency refers to the sudden, compelling need to have a bowel movement. Patients in remission typically have no urgency, while those with severe disease may experience constant urgency.


4. **Hemoglobin:** Hemoglobin levels are an indicator of anemia. In remission, patients typically have normal hemoglobin levels, while individuals with fulminant UC may require blood transfusions due to significantly reduced hemoglobin levels.


5. **ESR (Erythrocyte Sedimentation Rate):** ESR is a marker of inflammation. In remission, ESR is typically below 30, whereas patients with moderate to severe or fulminant disease may have ESR levels exceeding 30.


6. **CRP (C-Reactive Protein):** CRP is another inflammatory marker. In remission, CRP levels are normal, but they become elevated in moderate to severe and fulminant cases.


7. **FC (Fecal Calprotectin):** Fecal calprotectin measures inflammation in the gut. In remission, FC levels are generally less than 150-200 μg/g. Levels exceeding 150-200 μg/g are indicative of moderate to severe or fulminant disease.


8. **Endoscopy (Mayo Subscore):** Endoscopy evaluates the severity of mucosal inflammation. Scores range from 0 to 3, with higher scores indicating more significant inflammation.


9. **UCEIS (Ulcerative Colitis Endoscopic Index of Severity):** UCEIS provides an overall assessment of endoscopic severity, with scores ranging from 0 to 8. Higher scores indicate more severe disease.


Grading UC’s Severity

One crucial aspect of grading UC’s severity is the stratification of UCEIS scores. In a recent study, the UCEIS score was divided into four strata: remission (UCEIS 0–1), mild (UCEIS 2–4), moderate (UCEIS 5–6), and severe (UCEIS 7–8). This stratification offers a clear picture of the disease’s activity level.


Mucosal Healing

Mucosal healing, which is an important aspect of evaluating UC, is represented by the remission stratum (UCEIS 0–1). Mucosal healing is characterized by a healthy colonic lining, with little to no signs of inflammation, bleeding, or ulcerations. This state of healing is similar to the widely accepted Mayo ES 0 and 1, indicating mucosal healing in clinical trials.



Grading the severity of ulcerative colitis is vital for effective disease management. The Proposed American College of Gastroenterology Ulcerative Colitis Activity Index provides healthcare professionals with a structured approach to assessing disease activity, guiding treatment decisions, and improving patient outcomes. Additionally, understanding the concept of mucosal healing allows patients and healthcare providers to strive for remission and an improved quality of life. Grading systems ensure standardized assessment, facilitating communication, and aiding in the monitoring of UC’s progression. By working together, patients and healthcare providers can navigate the complexities of UC and pursue the goal of achieving mucosal healing, which greatly enhances the patient’s well-being.




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