Chapter

26 Inflammatory Bowel Disease

• There are two forms of inflammatory bowel disease (IBD): ulcerative colitis (UC), a
mucosal inflammatory condition confined to the rectum and colon, and Crohn
disease, a transmural inflammation of gastrointestinal (GI) mucosa that may
occur in any part of the GI tract. The etiologies of both conditions are unknown,
but they may have a common pathogenetic mechanism.

PATHOPHYSIOLOGY
• Factors involved in cause of IBD include infectious agents, genetics, the
environment, and the immune system. The microflora of the GI tract may
provide an environ-mental trigger to activate inflammation and are highly
implicated in the develop-ment of IBD. Several genetic markers and loci
have been identified that occur more frequently in patients with IBD. The
inflammatory response with IBD may indicate abnormal regulation of the
normal immune response or an autoimmune reaction to self-antigens.
• Th1 cytokine activity is excessive in CD and increased expression of interferon-γ in the
intestinal mucosa and production of IL-12 are features of the immune response in CD.
Tumor necrosis factor-α (TNF-α ) is a pivotal pro-inflammatory cytokine that is
increased in the mucosa and intestinal lumen of patients with CD and UC.
• Antineutrophil cytoplasmic antibodies are found in a high percentage of
patients with UC and less frequently with CD.
• Smoking appears to be protective for ulcerative colitis but associated with
increased frequency of Crohn disease. The use of nonsteroidal anti-inflammatory
drugs (NSAIDs) may trigger disease occurrence or lead to disease flares.
• UC and Crohn disease differ in two general respects: anatomical sites and
depth of involvement within the bowel wall. There is, however, overlap
between the two conditions, with a small fraction of patients showing
features of both diseases (Table 26–1).

ULCERATIVE COLITIS
• UC is confined to the colon and rectum and affects primarily the mucosa and
the submucosa. The primary lesion occurs in the crypts of the mucosa
(crypts of Lieberkühn) in the form of a crypt abscess.
• Local complications (involving the colon) occur in the majority of patients
with UC. Relatively minor complications include hemorrhoids, anal fissures,
and perirectal abscesses.
• A major complication is toxic megacolon, a severe condition that occurs in
up to 7.9% of UC patients admitted to hospitals. The patient with toxic
megacolon usually has a high fever, tachycardia, distended abdomen,
elevated white blood cell count, and a dilated colon.
• The risk of colonic carcinoma is much greater in patients with UC as
compared with the general population.
• Approximately 11% of patients with UC have hepatobiliary complications,
including fatty liver, pericholangitis, chronic active hepatitis, cirrhosis,
sclerosing cholangitis, cholangiocarcinoma, and gallstones.
• Arthritis commonly occurs in patients with IBD and is typically asymptomatic
and migratory. Arthritis typically involves one or a few large joints, such as
the knees, hips, ankles, wrists, and elbows.
• Ocular complications (iritis, episcleritis, and conjunctivitis) occur in 2% to 29% of
patients. Skin and mucosal lesions associated with IBD include erythema
nodosum, pyoderma gangrenosum, aphthous ulceration, and Sweet syndrome.

221
SECTION 5 | Gastrointestinal Disorders

TABLE 26–1 Comparison of the Clinical and Pathologic

Features of Crohn Disease and Ulcerative Colitis
Feature Crohn Disease Ulcerative Colitis
Clinical
Malaise, fever Common Uncommon
Rectal bleeding Common Common
Abdominal tenderness Common May be present
Abdominal mass Common Absent
Abdominal pain Common Unusual
Abdominal wall and internal fistulas Common Absent
Distribution Discontinuous Continuous
Aphthous or linear ulcers Common Rare
Pathologic
Rectal involvement Rare Common
Ileal involvement Very common Rare
Strictures Common Rare
Fistulas Common Rare
Transmural involvement Common Rare
Crypt abscesses Rare Very common
Granulomas Common Rare
Linear clefts Common Rare
Cobblestone appearance Common Absent

CROHN DISEASE
• Crohn disease is a transmural inflammatory process. The terminal ileum is the most
common site of the disorder, but it may occur in any part of the GI tract. Most patients
have some colonic involvement. Patients often have normal bowel separating
segments of diseased bowel; that is, the disease is often discontinuous.
• Complications of Crohn disease may involve the intestinal tract or organs
unrelated to it. Small bowel stricture with subsequent obstruction is a
complication that may require surgery. Fistula formation is common (20%–
40% lifetime risk) and occurs much more frequently than with UC.
• Systemic complications of Crohn disease are common and similar to those
found with UC. Arthritis, iritis, skin lesions, and liver disease often
accompany Crohn disease.
• Nutritional deficiencies are common with Crohn disease (weight loss, iron
deficiency anemia, vitamin B12 deficiency, folate deficiency,
hypoalbuminemia, hypokalemia, and osteomalacia).

CLINICAL PRESENTATION
ULCERATIVE COLITIS
• There is a wide range of presentation in UC, ranging from mild abdominal
cramp-ing with frequent small-volume bowel movements to profuse diarrhea
(Table 26–2). Many patients have disease confined to the rectum (proctitis).
• Most patients with UC experience intermittent bouts of illness after varying
intervals of no symptoms.
• Mild disease, which afflicts two thirds of patients, has been defined as fewer
than four stools daily, with or without blood, with no systemic disturbance
and a normal erythrocyte sedimentation rate (ESR).
• Patients with moderate disease have more than four stools per day but with
minimal systemic disturbance.
222
 Inflammatory Bowel Disease | CHAPTER 26

TABLE 26–2 Clinical Presentation of Ulcerative Colitis

Signs and symptoms
Ÿ Abdominal cramping
Ÿ Frequent bowel movements, often with blood in
the stool Ÿ Weight loss
Ÿ Fever and tachycardia in severe disease
Ÿ Blurred vision, eye pain, and photophobia with ocular
involvement Ÿ Arthritis
Ÿ Raised, tender red nodules that vary in size from 1 cm to several centimeters
Physical examination
Ÿ Hemorrhoids, fissures, or perirectal abscesses may be present.
Ÿ Iritis, uveitis, episcleritis, and conjunctivitis with ocular involvement
Ÿ Dermatologic findings with erythema nodosum, pyoderma
gangrenosum, or aphthous ulceration
Laboratory tests
Ÿ Decreased hematocrit/hemoglobin
Ÿ Increased erythrocyte sedimentation rate
Ÿ Leukocytosis and hypoalbuminemia with severe disease

Ÿ (+) perinuclear antineutrophil cytoplasmic antibodies

• With severe disease, the patient has more than six stools per day with
blood, with evidence of systemic disturbance as shown by fever,
tachycardia, anemia, or ESR greater than 30.
CROHN DISEASE
• As with UC, the presentation of Crohn disease is highly variable (Table 26–
3). A patient may present with diarrhea and abdominal pain or a perirectal or
perianal lesion.
• The course of Crohn disease is characterized by periods of remission and
exacerba-tion. Some patients may be free of symptoms for years, whereas
others experience chronic problems despite medical therapy.
• The Crohn Disease Activity Index (CDAI) and the Harvey Bradshw Index are used to
gauge response to therapy and determine remission. Disease activity may be
assessed and correlated by evaluation of serum C-reactive protein concentrations.

TABLE 26–3 Clinical Presentation of Crohn Disease

Signs and symptoms
Ÿ Malaise and fever
Ÿ Abdominal pain
Ÿ Frequent bowel movements
Ÿ Hematochezia
Ÿ Fistula
Ÿ Weight loss and malnutrition
Ÿ Arthritis
Physical examination
Ÿ Abdominal mass and tenderness
 Ÿ Perianal fissure or fistula
Laboratory tests
Ÿ Increased white blood cell count and erythrocyte sedimentation rate
Ÿ Anti–Saccharomyces cerevisiae antibodies

223
SECTION 5 | Gastrointestinal Disorders

TREATMENT
• Goals of Treatment: Resolution of acute inflammatory processes, resolution
of atten-dant complications (eg, fistulas or abscesses), alleviation of
systemic manifestations (eg, arthritis), maintenance of remission from acute
inflammation, or surgical pal-liation or cure.
NONPHARMACOLOGIC TREATMENT
• Protein–energy malnutrition and suboptimal weight is reported in up to 85%
of patients with CD.
• The nutritional needs of the majority of patients can be adequately addressed
with enteral supplementation. Parenteral nutrition is generally reserved for
patients with severe malnutrition or those who fail enteral therapy or have a
contraindication to receiving enteral therapy, such as perforation, protracted
vomiting, short bowel syn-drome, or severe intestinal stenosis.
• Probiotic formulas have been effective for inducing and maintaining
remission in UC, but the data are not conclusive.
• For UC, colectomy may be indicated for patients with long-standing disease
(>8 to 10 years), as a prophylactic measure against the development of
CRC, and for patients with premalignant changes (severe dysplasia) on
surveillance mucosal biopsies.
• The indications for surgery with Crohn disease are not as well established
as they are for UC, and surgery is usually reserved for the complications of
the disease. There is a high recurrence rate of Crohn disease after surgery.
PHARMACOLOGIC THERAPY
• The major types of drug therapy used in IBD are aminosalicylates,
glucocorticoids, immunosuppressive agents (azathioprine, mercaptopurine,
cyclosporine, and methotrexate), antimicrobials (metronidazole and
ciprofloxacin), agents to inhibit tumor necrosis factor-α (TNF-α) (anti–TNF-α
antibodies), and leukocyte adhesion and migration (natalizumab).
• Sulfasalazine combines a sulfonamide (sulfapyridine) antibiotic and
mesalamine (5-aminosalicylic acid) in the same molecule. Mesalamine-
based products are listed in Table 26–4.
• Corticosteroids and adrenocorticotropic hormone have been widely used for
the treatment of UC and Crohn disease and are used in moderate to severe
disease. Prednisone is most commonly used. Immunosuppressive agents
such as azathio-prine and mercaptopurine (a metabolite of azathioprine) are
used in the long-term treatment of IBD. These agents are generally
reserved for patients who fail mesa-lamine therapy or are refractory to or
dependent on corticosteroids. Cyclosporine has been of short-term benefit
in acute, severe UC when used in a continuous infusion.
• Methotrexate given 25 mg intramuscularly once weekly is useful for
treatment and maintenance of Crohn disease.
• Antimicrobial agents, particularly metronidazole, are frequently used in attempts
to control Crohn disease, particularly when it involves the perineal area or
fistulas. Ciprofloxacin has also been used for treatment of Crohn disease.
• Infliximab is an anti-TNF antibody that is useful in moderate to severe active
disease and steroid-dependent or fistulizing disease, but the cost far
exceeds that of other regimens. Adalimumab is another anti-TNF antibody
that is an option for patients with moderate to severe active Crohn disease
or UC previously treated with infliximab who have lost response.
Natalizumab is a leukocyte adhesion and migration inhibitor that is used for
patients with Crohn disease who are unrespon-sive to other therapies.

224
 Inflammatory Bowel Disease | CHAPTER 26

TABLE 26–4 Agents for the Treatment of Inflammatory Bowel Disease

Drug Brand Name Initial Dose (g) Usual Range
Sulfasalazine Azulfidine 500 mg to 1 g 4–6 g/day
Azulfidine EN 500 mg to 1 g 4–6 g/day
Mesalamine supposi- Rowasa 1g 1 g daily to three times
tory weekly
Mesalamine enema Canasa 4g 4 g daily to three times
weekly
Mesalamine (oral) Asacol 1.2 g/day 2.8–4.8 g/day
Asacol HD 1.6 g/day 2.8–4.8 g/day
Apriso 1.5 g/day 1.5 g/day once daily
Lialda 1.2–2.4 g/day 1.2–4.8 g/day once daily
Pentasa 2 g/day 2–4 g/day
Delzicol 1.2 g/day 2.4–4.8 g/day
Olsalazine Dipentum 1.5 g/day 1.5–3 g/day
Balsalazide Colazal 2.25 g/day 2.25–6.75 g/day
Azathioprine Imuran, Azasan 50–100 mg 1–2.5 mg/kg/day
Cyclosporine Gengraf 2–4 mg/kg/day IV 2–4 mg/kg/day IV
Neoral, 2–8 mg/kg/day oral
Sandimmune
Mercaptopurine Purinethol 50–100 mg 1–2.5 mg/kg/day
Methotrexate Trexall 15–25 mg IM weekly 15–25 mg IM weekly
Adalimumab Humira 160 mg SC day 1 80 mg SC 2 (day 15), and
then 40 mg every 2
weeks
Certolizumab Cimzia 400 mg SC 400 mg SC weeks 2 and
4, and then 400 mg SC
monthly
Infliximab Remicade 5 mg/kg IV 5 mg/kg weeks 2 and 6,
5–10 mg/kg every
8 weeks
Natalizumab Tysabri 300 mg IV 300 mg IV every 4 weeks
Budesonide Enterocort EC 9 mg 6–9 mg daily
Uceris

SC, subcutaneous; IM, intramuscular.

Ulcerative Colitis
MILD TO MODERATE DISEASE
• Most patients with mild to moderate active UC can be managed on an outpatient
basis with oral and/or topical mesalamine (Fig. 26–1). When given orally, usually
4 g/day to 6 g/day of sulfasalazine is required to attain control of active
inflammation. Sulfasalazine therapy should be instituted at 500 mg/day and
increased every few days up to 4 g/day or the maximum tolerated.
• Oral mesalamine derivatives (such as those listed in Table 26–4) are reasonable
alter-natives to sulfasalazine for treatment of UC as they are better tolerated.

225
SECTION 5 | Gastrointestinal Disorders

Consider reducing oral

Disease severity
Distal
mesalamine or sulfasalazine
Oral
dose to
sulfasalazine or
Mild 2.4 g/day, or mesalamine
mesalamine, or mesalamine Remission
enema 4 g every 1–2 days,
enema (2–4 g/day left sided), or
suppository 1 g/day (proctitis), or suppository 1 g every 1–2
or corticosteroid enema days

Colitis Reduce sulfasalazine

Sulfasalazine 4– or
6 g/day mesalamine dose to 2.4 g/day
or or
Moderate oral mesalamine 2.4–4.8 g/day continue budesonide for
Remission or up to 8 weeks

controlled
release Taper prednisone, then after
budesonide 9 1–2 mo reduce sulfasalazine
mg/day or mesalamine dose to those
listed above
Sulfasalazine 4–
Severe 6 g/day Add azathioprine,
or
mercaptopurine, infliximab, or
oral mesalamine Remission
adalimumab
2.4–4.8 g/day
PLUS
prednisone 40–
Change to prednisone
60 mg/day

Add azathioprine,
Fulminant mercaptopurine, infliximab, or
Inadequate or no response adalimumab attempt to
withdraw steroids
after 1–2 mo, consider
Hydrocortisone IV Remission adding aminosalicylate back
100 mg every 6–8 h Remission
No response in 5–7 days
Maintain TNF-α inhibitor
Cyclosporine IV or immunomodulator
4 mg/kg/day
Remission

Change to oral
cyclosporine
and add
azathioprine/mer
captopurine
FIGURE 26–1. Treatment approaches for ulcerative colitis.

MODERATE TO SEVERE DISEASE

• Steroids have a place in the treatment of moderate to severe UC or in those
who are unresponsive to maximal doses of oral and topical mesalamine.
Oral prednisone 40 to 60 mg daily is recommended for adult.
• Infliximab is another viable option for patients with moderate to severe active UC
who are unresponsive to steroids or other immunosuppressive agents.
SEVERE OR INTRACTABLE DISEASE
• Patients with uncontrolled severe colitis or incapacitating symptoms require hospital-
ization for effective management. Most medication is given by the parenteral route.
• IV hydrocortisone 300 mg daily in three divided doses or methylprednisolone
60 mg once daily is considered a first-line agent. A trial of steroids is
 warranted in most patients before proceeding to colectomy, unless the
condition is grave or rapidly deteriorating.

226
 Inflammatory Bowel Disease | CHAPTER 26

• Patients who are unresponsive to parenteral corticosteroids after 3 to 7 days can

receive cyclosporine or infliximab. A continuous IV infusion of cyclosporine 2 to 4
mg/kg/day is the typical dose range utilized and may delay the need for colectomy.
MAINTENANCE OF REMISSION
• Once remission from active disease has been achieved, the goal of therapy
is to maintain the remission.
• Oral agents, including sulfasalazine, mesalamine, and balsalazide, are all effective
options for maintenance therapy. The optimal dose to prevent relapse is 2 to 2.4 g/day
of mesalamine equivalent, with rates of relapse over 6 to 12 months reported as 40%.
• Steroids do not have a role in the maintenance of remission with UC
because they are ineffective. Steroids should be gradually withdrawn after
remission is induced (over 2–4 weeks).
Crohn Disease
ACTIVE CROHN DISEASE
• Mesalamine derivatives have not demonstrated significant efficacy in CD.
They are often tried as an initial therapy for mild to moderate CD given their
favorable adverse effect profile.
• Mesalamine derivatives (e.g., Pentasa and Asacol) that release mesalamine in the
small bowel may be more effective than sulfasalazine for ileal involvement.
• Oral corticosteroids, such as prednisone 40 to 60 mg/day, are generally considered first-line
therapies and are frequently used for the treatment of moderate to severe Crohn disease.
Budesonide (Entocort) at a dose of 9 mg daily is a viable first-line option for patients with mild
to moderate ileal or right-sided (ascending colonic) disease.
• Metronidazole, given orally as 10 to 20 mg/kg/day in divided doses, may be
use-ful in some patients with CD, particularly for patients with colonic or
ileocolonic involvement, those with perineal disease, or those who are
unresponsive to sulfasalazine.
• Azathioprine and mercaptopurine are not recommended to induce remission
in moderate to severe CD; however, they are effective in maintaining
steroid-induced remission and are generally limited to use for patients not
achieving adequate response to standard medical therapy or in the setting
of steroid dependency. The usual doses of azathioprine are 2 to 3
mg/kg/day, and for mercaptopurine 1 to 1.5 mg/kg/day. Starting doses are
typically 50 mg/day and increased at 2-week intervals.
• Patients deficient in thiopurine S-methyltransferase (TPMT) are at greater risk of
bone marrow suppression from azathioprine and mercaptopurine. Determination
of TPMT or TPMT genotype is recommended to guide dosage.
• Cyclosporine is not recommended for Crohn disease except for patients with symp-
tomatic and severe perianal or cutaneous fistulas. The dose of cyclosporine is impor-
tant in determining efficacy. An oral dose of 5 mg/kg/day was not effective, whereas 7.9
mg/kg/day was effective. However, toxic effects limit application of the higher dosage.
Dosage should be guided by cyclosporine whole-blood concentrations.
• Methotrexate, given as a weekly injection of 25 mg, has demonstrated efficacy
for induction of remission in Crohn disease, as well as for maintenance therapy.
The risks are bone marrow suppression, hepatotoxicity, and pulmonary toxicity.
• Infliximab is used for moderate to severe active Crohn disease in patients failing
immunosuppressive therapy, in those who are corticosteroid dependent, and for
treatment of fistulizing disease. A single, 5 mg/kg infusion is effective when given every
day for 8 weeks. Additional doses at 2 and 6 weeks following the initial dose results in
higher response rates. Patients may develop antibodies to infliximab, which can result
in serious infusion reactions and loss of drug response.
• Adalimumab and certolizumab are effective in patients with moderate to
severe Crohn disease who have lost response to infliximab. Natalizumab is
reserved for patients who do not respond to steroids or the TNF inhibitors.

227
SECTION 5 | Gastrointestinal Disorders

Disease severity

Mild
Ileocolonic or colonic

Sulfasalazine 3–6 g/day Perianal Small bowel

or Sulfasalazine or oral Oral mesalamine 2.4–4 g/day
oral mesalamine 2.4–4.8 g/day mesalamine and/or or metronidazole.
or metronidazole Budesonide 9 mg/day for
metronidazole/ up to 10–20 mg/kg/day terminal ileal or ascending
+/– ciprofloxacin colonic disease

Moderate
Steroid

refractory and/or fistulizing Response Taper prednisone

As above plus disease add infliximab after 2–4 weeks
prednisone adalimumab or
40–60 mg/day certolizumab +/– Add azathioprine, mercaptopurine,
azathioprine or or methotrexate; change to
natalizumab if no response
mercaptopurine to TNF-α inhibitor or
Severe immunomodulator

Cyclosporine IV

Hydrocortisone 100 mg 4 mg/kg/day or infliximab

IV every 6–8 h No response in 5–7 days 5 mg/kg if not attempted prior

Fulminant

FIGURE 26–2. Treatment approaches for Crohn disease.

MAINTENANCE OF REMISSION
• Prevention of recurrence of disease is clearly more difficult with Crohn disease
than with ulcerative colitis. Sulfasalazine and oral mesalamine derivatives are
effective in preventing acute recurrences in quiescent Crohn disease (Fig. 26-2).
• Systemic steroids or budesonide also have no place in the prevention of
recurrence of Crohn disease; these agents do not appear to alter the long-
term course of the disease. Budesonide can be considered for maintenance
therapy for up to 1 year, par-ticularly in patients who have become
corticosteroid dependent, for whom switching to budesonide is an option.
• Azathioprine and MP are effective in maintaining remission in CD in up to 70% of patients,
particularly in infliximab- or steroid-induced remission, and therefore these drugs are
generally considered first-line agents. There is evidence to suggest that, meth-otrexate, the
TNF-α inhibitors are effective in maintaining remission in Crohn disease.
SELECTED COMPLICATIONS
Toxic Megacolon
• The treatment required for toxic megacolon includes general supportive
measures to maintain vital functions, consideration for early surgical
intervention, and antimicrobials.
• Aggressive fluid and electrolyte management are required for dehydration.
When the patient has lost significant amounts of blood (through the rectum),
blood replace-ment is also necessary.
• Steroids in high dosages (hydrocortisone 100 mg every 8 hours) should be
adminis-tered IV to reduce acute inflammation.
• Broad-spectrum antimicrobials that include coverage for gram-negative
bacilli and intestinal anaerobes should be used as preemptive therapy in the
event that perfora-tion occurs.
Systemic Manifestations
• For arthritis, aspirin or another NSAID may be beneficial, as are
corticosteroids. However, NSAID use may exacerbate the underlying IBD
and predispose patients to GI bleeding.
• Anemia secondary to blood loss from the GI tract can be treated with oral
ferrous sulfate. Vitamin B12 or folic acid may also be required.
228
 Inflammatory Bowel Disease | CHAPTER 26

TABLE 26–5 Drug Monitoring Guidelines

Monitoring
Drug(s) Adverse Drug Reaction Parameters Comments
Sulfasalazine Nausea, vomiting, headache Folate, complete blood Increase the dose
Rash, anemia, pneumonitis count slowly,
Hepatotoxicity, nephritis Liver function tests, over 1–2 weeks
Thrombocytopenia, lym- Scr, BUN
phoma
Mesalamine Nausea, vomiting, headache GI disturbances
Corticosteroids Hyperglycemia, dyslipid- Blood pressure, fasting Avoid long-term use
emia lipid panel if possible or con-
sider budesonide
Osteoporosis, hypertension, Glucose, vitamin D,
acne bone density
Edema, infection, myopathy,
psychosis
Azathioprine/ Bone marrow suppression, Complete blood count Check TMPT activity
mercaptopu- pancreatitis
rine
Liver dysfunction, rash, Scr, BUN, liver function
arthralgia tests, genotype/
phenotype
Methotrexate Bone marrow suppression, Complete blood count Check baseline
pancreatitis Scr, BUN pregnancy test
Pneumonitis, pulmonary Liver function tests Chest x-ray
fibrosis, hepatitis
Infliximab Infusion-related reactions Blood pressure/heart Need negative PPD
(infliximab), infection rate (infliximab) and viral serologies
Adalimumab Heart failure, optic neuritis, Neurologic exam,
demyelination, injection site mental status
reaction, signs of infection
Certolizumab Lymphoma Trough concentrations
(infliximab)
Natalizumab Infusion-related reactions Brain MRI, mental
status, progressive
multifocal leukoen-
cephalopathy

EVALUATION OF THERAPEUTIC OUTCOMES

• See Table 26-5 for drug monitoring guidelines.
• Patients receiving sulfasalazine should receive oral folic acid
supplementation, as sulfasalazine inhibits folic acid absorption.
• The success of therapeutic regimens to treat IBDs can be measured by
patient-reported complaints, signs and symptoms, direct physician
examination (including endoscopy), history and physical examination,
selected laboratory tests, and quality of life measures.
• To create more objective measures, disease-rating scales or indices have been cre-
ated. The Crohn Disease Activity Index is a commonly used scale, particularly for
evaluation of patients during clinical trials. The scale incorporates eight elements: (1)
number of stools in the past 7 days, (2) sum of abdominal pain ratings from the past

229
SECTION 5 | Gastrointestinal Disorders

7 days, (3) rating of general well-being in the past 7 days, (4) use of antidiarrheals,
(5) body weight, (6) hematocrit, (7) finding of abdominal mass, and (8) a sum of
symptoms present in the past week. Elements of this index provide a guide for
those measures that may be useful in assessing the effectiveness of treatment
regimens. The Perianal CD Activity Index is used for perianal Crohn disease.
• Standardized assessment tools have also been constructed for UC. Elements in
these scales include (1) stool frequency; (2) presence of blood in the stool; (3)
mucosal appearance (from endoscopy); and (4) physician’s global assessment
based on physi-cal examination, endoscopy, and laboratory data.

See Chapter 21, Inflammatory Bowel Disease, authored by Brian A. Hemstreet, for a
more detailed discussion of this topic.

230