Unifying Concepts

Ulcerative Colitis Activity Index

Ulcerative colitis (UC) is a chronic immune-mediated inflammatory condition of the large intestine that is frequently associated with inflammation of the rectum but often extends proximally to involve additional areas of the colon. Once a diagnosis of UC is made, determining the severity of disease becomes important.

Proposed American College of Gastroenterology Ulcerative Colitis Activity Index

Remission Mild Moderate-severe Fulminant
Stools (no./d) Formed stools <4 >6 >10
Blood in stools None Intermittent Frequent Continuous
Urgency None Mild, occasional Often Continuous
Hemoglobin Normal Normal 75% of normal Transfusion required
ESR <30 <30 >30 >30
CRP (mg/L) Normal Elevated Elevated Elevated
FC (µg/g) <150–200 >150–200 >150–200 >150–200
Endoscopy (Mayo subscore) 0-1 1 2-3 3
UCEIS 0-1 2-4 5-8 7-8

The above factors are general guides for disease activity. With the exception of  remission, a patient does not need to have all the factors to be considered in a specific category.
CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; FC, fecal calprotectin; UCEIS, Ulcerative Colitis Endoscopic Index of Severity

Mayo score for ulcerative colitis activity

Parameter Subscore (0–3)
Stool frequency 0 = normal number of stools
1 = 1–2 stools more than normal
2 = 3–4 stools more than normal
3 = 5 or more stools more than normal
Rectal bleeding 0 = no blood seen
1 = streaks of blood with stool less than one-half of the time
2 = obvious blood with stool most of the time
3 = blood alone passed without stool
Findings on endoscopy 0 = normal or inactive disease
1 = mild disease (erythema, decreased vascular pattern, and mild friability)
2 = moderate disease (marked erythema, lack of vascular pattern, friability, and erosions)
3 = severe disease (spontaneous bleeding and ulcerations)
Physician’s global
0 = normal
1 = mild disease
2 = moderate disease
3 = severe disease

Simple Clinical Colitis Activity Index

Symptom Score
Bowel frequency (d) 1-3 0
4-6 1
7-9 2
9+ 3
Bowel frequency (night) 0 0
1-3 1
4-6 2
Urgency of defecation None 0
Hurry 1
Immediate 2
Incontinence 3
Blood in stool None 0
Trace 1
Occasionally frank 2
Usually frank 3
General well-being Very well 0
Slightly below par 1
Poor 2
Very poor 3
Terrible 4
Extracolonic features  1 per manifestation


Ulcerative Colitis Endoscopic Index of Severity

Descriptor Likert scale anchor points Definitions
Vascular pattern 0 = normal Normal vascular pattern with arborizations of capillaries clearly defined
1 = patchy obliteration Patchy obliteration of vascular pattern
2 = obliterated Complete loss of vascular pattern
Bleeding 0 = none No visible blood
1 = mucosal Spots or streaks of coagulated blood on the mucosa surface, which can be washed off
2 = luminal mild Some free liquid blood in the lumen
3 = luminal moderate or severe Frank blood in the lumen or visible oozing from the mucosa after washing or visible oozing from a hemorrhagic mucosa
Erosions and ulcers 0 = none Normal mucosa, no visible ulcers or erosions
1 = erosions Small defects in the mucosa (≤5 mm), white or yellow, flat edge
2 = superficial ulcer Larger defects in the mucosa (>5 mm), discrete fibrin covered, remain superficial
3 = deep ulcer Deeper excavated defects in the mucosa, with a slightly raised edge


Poor prognostic factors in ulcerative colitis disease severity

  • Age <40 yr at diagnosis
  • Extensive colitis
  • Severe endoscopic disease (Mayo endoscopic subscore 3, UCEIS ≥ 7)
  • Hospitalization for colitis
  • Elevated CRP
  • Low serum albumin

The greater the number of poor prognostic factors, the worse the prognosis as measured by the likelihood of colectomy.



  1. Rubin DT, Ananthakrishnan AN, Siegel CA, Sauer BG, Long MD. ACG Clinical Guideline: Ulcerative Colitis in Adults. Am J Gastroenterol. 2019 Mar;114(3):384-413. [Medline]
  2. Matsuoka K, Kobayashi T, Ueno F, Matsui T, Hirai F, Inoue N, Kato J, Kobayashi K, Kobayashi K, Koganei K, Kunisaki R, Motoya S, Nagahori M, Nakase H, Omata F, Saruta M, Watanabe T, Tanaka T, Kanai T, Noguchi Y, Takahashi KI, Watanabe K, Hibi T, Suzuki Y, Watanabe M, Sugano K, Shimosegawa T. Evidence-based clinical practice guidelines for inflammatory bowel disease. J Gastroenterol. 2018 Mar;53(3):305-353. [Medline]


Created Sep 25, 2019

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