Advances in the Assessment of Disease Activity in Inflammatory Bowel Disease
1989; Elsevier BV; Volume: 64; Issue: 7 Linguagem: Inglês
10.1016/s0025-6196(12)61753-4
ISSN1942-5546
AutoresMichael Camilleri, Maritza Proano,
Tópico(s)Autoimmune and Inflammatory Disorders
ResumoKnowledge of the severity and extent of the inflammation in inflammatory bowel diseases provides a means of determining rational therapeutic strategies in affected patients. During the past 3 decades, several clinical, laboratory, and combined indices have been proposed for the assessment of inflammatory bowel disease; refinements in radiologic methods and the availability of endoscopy and biopsy have facilitated the accurate assessment of the extent and severity of the disease. In relapsing conditions such as inflammatory bowel disease, however, the use of such procedures is limited by the radiation exposure or the relatively invasive nature of the technique. In this article, we review the proposed methods and recent advances in assessment of patients with inflammatory bowel disease; we also discuss possible strategies at the time of diagnosis, during recurrence, and in evaluation of the efficacy of drug or dietetic therapy. Knowledge of the severity and extent of the inflammation in inflammatory bowel diseases provides a means of determining rational therapeutic strategies in affected patients. During the past 3 decades, several clinical, laboratory, and combined indices have been proposed for the assessment of inflammatory bowel disease; refinements in radiologic methods and the availability of endoscopy and biopsy have facilitated the accurate assessment of the extent and severity of the disease. In relapsing conditions such as inflammatory bowel disease, however, the use of such procedures is limited by the radiation exposure or the relatively invasive nature of the technique. In this article, we review the proposed methods and recent advances in assessment of patients with inflammatory bowel disease; we also discuss possible strategies at the time of diagnosis, during recurrence, and in evaluation of the efficacy of drug or dietetic therapy. The assessment of disease activity and extent in ulcerative colitis and Crohn's disease is a prerequisite for the rational choice of therapy for these disorders.1Truelove SC Witts LJ Cortisone in ulcerative colitis: final report on a therapeutic trial.Br Med J. 1955; 2: 1041-1048Crossref PubMed Scopus (2194) Google Scholar, 2Summers RW Switz DM Sessions Jr, JT Becktel JM Best WR Kern Jr, F Singleton JW National Cooperative Crohn's Disease Study: results of drug treatment.Gastroenterology. 1979; 77: 847-869PubMed Scopus (1068) Google Scholar Such determinations are also necessary in the assessment of the effects of drug therapy,3Hodgson HJF Assessment of drug therapy in inflammatory bowel disease.Br J Clin Pharmacol. 1982; 14: 159-170Crossref PubMed Scopus (17) Google Scholar and they facilitate the comparison of data collected in cooperative trials and in the study of the natural history of inflammatory bowel disorders. In general, four categories for assessment of disease activity have been proposed: (1) clinical criteria; (2) single laboratory indices; (3) radiology or endoscopy, with or without biopsies; and (4) noninvasive imaging with radiolabeled autologous leukocytes and collection of stool specimens for quantitation of excreted radiolabel. The purposes of this article are to review the advantages and disadvantages of these methods and to propose rational strategies to be followed in clinical practice and research. Clinical features suggestive of ulcerative colitis include frequent loose stools in association with blood and mucus; those suggestive of Crohn's disease are severe abdominal pain, tenderness, mass, distention, and fistulization.4Myren J Bouchier IAD Watkinson G Softley A Clamp SE de Dombal FT The O.M.G.E. multinational inflammatory bowel disease survey 1976–1982: a further report on 2,657 cases.Scand J Gastroenterol Suppl. 1984; 95: 1-27PubMed Google Scholar Various combinations of these symptoms have been developed as clinical criteria in an attempt to assess inflammatory activity adequately in inflammatory bowel disease. One of the earliest attempts at using clinical criteria for assessing disease activity was made by Truelove and Witts1Truelove SC Witts LJ Cortisone in ulcerative colitis: final report on a therapeutic trial.Br Med J. 1955; 2: 1041-1048Crossref PubMed Scopus (2194) Google Scholar during studies on the effects of corticosteroid therapy in patients with ulcerative colitis. Their assessment of disease activity in ulcerative colitis included laboratory measurements, such as hemoglobin concentration and erythrocyte sedimentation rate (Table 1). Such criteria are extremely useful as they depend primarily on clinical findings and widely available laboratory measurements.Table 1Proposed Criteria for Assessment of Disease Activity in Ulcerative ColitisFactorSevere*Moderate disease is intermediate between severe and mild classifications.MildBowel frequency≥6 daily≤4 dailyBlood in stool++±Temperature>37.5°C on 2 of 4 daysNormalPulse rate (beats/min)>90NormalHemoglobin (allow for transfusion)≤75%Normal or near normalErythrocyte sedimentation rate (mm in 1 h)>30≤30Data from Truelove and Witts.1Truelove SC Witts LJ Cortisone in ulcerative colitis: final report on a therapeutic trial.Br Med J. 1955; 2: 1041-1048Crossref PubMed Scopus (2194) Google Scholar* Moderate disease is intermediate between severe and mild classifications. Open table in a new tab Data from Truelove and Witts.1Truelove SC Witts LJ Cortisone in ulcerative colitis: final report on a therapeutic trial.Br Med J. 1955; 2: 1041-1048Crossref PubMed Scopus (2194) Google Scholar De Dombal and associates5De Dombal FT Burton IL Clamp SE Goligher JC Short-term course and prognosis of Crohn's disease.Gut. 1974; 15: 435-443Crossref PubMed Scopus (103) Google Scholar modified these criteria by adding weight loss and abdominal pain, both prominent features of Crohn's disease, and applied these criteria to patients with active Crohn's disease. In the 1970s, the Crohn's disease activity index (CDAI) was developed for use in the National Cooperative Crohn's Disease Study. It was hoped that such a disease activity index would allow uniformity in clinical evaluation and in monitoring disease response to various medical treatments in clinical trials.6Best WR Becktel JM Singleton JW Kern Jr, F Development of a Crohn's disease activity index: National Cooperative Crohn's Disease Study.Gastroenterology. 1976; 70: 439-444Abstract Full Text PDF PubMed Scopus (3020) Google Scholar Eight clinical variables were assigned various weighting scores, which are summed to yield a total symptom score indicative of inflammatory activity. A score of less than 150 indicates quiescence, whereas a score between 150 and 450 denotes increasing severity of disease. The CDAI, however, includes several subjective factors, such as general well-being, and is cumbersome, inasmuch as patients must maintain a diary of symptoms for 7 consecutive days. Because of these shortcomings, the CDAI has been modified not only by its original developers but also by others. Harvey and Bradshaw7Harvey RF Bradshaw JM A simple index of Crohn'sdisease activity.Lancet. 1980; 1: 514Abstract PubMed Scopus (2135) Google Scholar reduced the number of clinical variables to five, simplified the numerical calculation, and shortened the period of clinical observation from 7 days to 1 day. This simplified index of Crohn's disease activity (Table 2) was further modified by the Organisation Mondiale de Gastroenterologie (OMGE) by limiting the maximal score for increased number of bowel movements to five.4Myren J Bouchier IAD Watkinson G Softley A Clamp SE de Dombal FT The O.M.G.E. multinational inflammatory bowel disease survey 1976–1982: a further report on 2,657 cases.Scand J Gastroenterol Suppl. 1984; 95: 1-27PubMed Google ScholarTable 2Variables Used for Assessment of Crohn's Disease Activity, as Proposed by the Organisation Mondiale de Gastroenterologie1.General well-being (0 = very well; 1 = slightly below par; 2 = poor; 3 = very poor; 4 = terrible)2.Abdominal pain (0 = none; 1 = mild; 2 = moderate; 3 = severe)3.Number of bowel movements (0 = normal; 5 = ≥10/day)4.Abdominal mass (0 = none; 1 = dubious; 2 = definite; 3 = definite and tender)5.Complications (score of 1 for each): arthralgia, uveitis, erythema nodosum, aphthous ulcers, pyoderma gangrenosum, anal fissure, new fistula, abscessData from Myren and associates.4Myren J Bouchier IAD Watkinson G Softley A Clamp SE de Dombal FT The O.M.G.E. multinational inflammatory bowel disease survey 1976–1982: a further report on 2,657 cases.Scand J Gastroenterol Suppl. 1984; 95: 1-27PubMed Google Scholar Open table in a new tab Data from Myren and associates.4Myren J Bouchier IAD Watkinson G Softley A Clamp SE de Dombal FT The O.M.G.E. multinational inflammatory bowel disease survey 1976–1982: a further report on 2,657 cases.Scand J Gastroenterol Suppl. 1984; 95: 1-27PubMed Google Scholar A less quantitative assessment of disease activity was proposed by the International Organisation of Inflammatory Bowel Disease (IOIBD) at a meeting in Oxford, England, in 1980. The weighting of symptoms with different scores was eliminated. Instead, a simple severity score ranging from 1 to 10 was calculated by attributing one point to each of 10 symptoms or signs.4Myren J Bouchier IAD Watkinson G Softley A Clamp SE de Dombal FT The O.M.G.E. multinational inflammatory bowel disease survey 1976–1982: a further report on 2,657 cases.Scand J Gastroenterol Suppl. 1984; 95: 1-27PubMed Google Scholar Other clinical indices, including the Cape Town index8Wright JP Marks IN Parfitt A A simple clinical index of Crohn's disease activity—the Cape Town index.S Afr Med J. 1985; 68: 502-503PubMed Google Scholar and the Dutch activity index,9Van Hees PAM van Elteren PH van Lier HJJ van Tongeren JHM An index of inflammatory activity in patients with Crohn's disease.Gut. 1980; 21: 279-286Crossref PubMed Scopus (313) Google Scholar have been developed and have been used in epidemiologic research.10Sandler RS Jordan MC Kupper LL Development of a Crohn's index for survey research.J Clin Epidemiol. 1988; 41: 451-458Abstract Full Text PDF PubMed Scopus (61) Google Scholar The correlation between these indices and the final clinical diagnosis was evaluated conjointly by the OMGE Research Committee and the IOIBD.4Myren J Bouchier IAD Watkinson G Softley A Clamp SE de Dombal FT The O.M.G.E. multinational inflammatory bowel disease survey 1976–1982: a further report on 2,657 cases.Scand J Gastroenterol Suppl. 1984; 95: 1-27PubMed Google Scholar Assessment of 200 patients with Crohn's disease of the large bowel was based on the OMGE version of Harvey and Bradshaw's simplified CDAI7Harvey RF Bradshaw JM A simple index of Crohn'sdisease activity.Lancet. 1980; 1: 514Abstract PubMed Scopus (2135) Google Scholar (Table 2), the Oxford IOIBD index,4Myren J Bouchier IAD Watkinson G Softley A Clamp SE de Dombal FT The O.M.G.E. multinational inflammatory bowel disease survey 1976–1982: a further report on 2,657 cases.Scand J Gastroenterol Suppl. 1984; 95: 1-27PubMed Google Scholar and the Dutch index.9Van Hees PAM van Elteren PH van Lier HJJ van Tongeren JHM An index of inflammatory activity in patients with Crohn's disease.Gut. 1980; 21: 279-286Crossref PubMed Scopus (313) Google Scholar The modified CDAI correlated well with the clinical diagnosis, unlike the Dutch activity index. The Oxford IOIBD index compared favorably with the modified CDAI. Thus, the modified CDAI and Oxford IOIBD index allowed the clinician to gauge the severity of the inflammatory activity promptly and with reasonable accuracy and were therefore recommended by the OMGE and IOIBD. These indices, however, are not readily reproducible, even among investigators with interest in inflammatory bowel disease,11De Dombal FT Softley A IOIBD report no 1: observer variation in calculating indices of severity and activity in Crohn's disease.Gut. 1987; 28: 474-481Crossref PubMed Scopus (112) Google Scholar and interobserver variations detract from their utility in clinical trials. Although relatively accurate in assessing inflammatory activity in certain clinical settings, these disease activity indices may provide erroneous information. The classic example is that of fibrous stricturing in Crohn's disease; a high score for abdominal pain in this instance is due to a fibrotic lesion and not to any medically relievable inflammatory activity. Hence, several laboratory indices, either alone or in combination with clinical criteria, have been proposed for more objective assessment of inflammatory activity. In summary, Truelove and Witts' criteria for ulcerative colitis1Truelove SC Witts LJ Cortisone in ulcerative colitis: final report on a therapeutic trial.Br Med J. 1955; 2: 1041-1048Crossref PubMed Scopus (2194) Google Scholar and the OMGE version of Harvey and Bradshaw's modification of the CDAI for Crohn's disease7Harvey RF Bradshaw JM A simple index of Crohn'sdisease activity.Lancet. 1980; 1: 514Abstract PubMed Scopus (2135) Google Scholar are the most widely accepted and clinically applicable indices. During the past 3 decades, numerous single laboratory measurements (Table 3) on blood, urine, feces, and tissue have been proposed for the assessment of disease activity in inflammatory bowel disease.12Sachar DB Smith H Chan S Cohen LB Lichtiger S Messer J Erythrocyte sedimentation rate as a measure of clinical activity in inflammatory bowel disease.J Clin Gastroenterol. 1986; 8: 647-650Crossref PubMed Scopus (73) Google Scholar, 13Chambers RE Stross P Barry RE Whicher JT Serum amyloid A protein compared with C-reactive protein, alpha 1-antichymotrypsin and alpha 1-acid glycoprotein as a monitor of inflammatory bowel disease.Eur J Clin Invest. 1987; 17: 460-467Crossref PubMed Scopus (70) Google Scholar, 14Fagan EA Dyck RF Maton PN Hodgson HJF Chadwick VS Petrie A Pepys MB Serum levels of C-reactive protein in Crohn's disease and ulcerative colitis.Eur J Clin Invest. 1982; 12: 351-359Crossref PubMed Scopus (246) Google Scholar, 15André C Descos L Vignal J Gillon J C-reactive protein as a predictor of relapse in asymptomatic patients with Crohn's disease.Scott Med J. 1983; 28: 26-29PubMed Google Scholar, 16Dearing WH McGuckin WF Elveback LR Serum α1acid glycoprotein in chronic ulcerative colitis.Gastroenterology. 1969; 56: 295-303PubMed Scopus (31) Google Scholar, 17Helman CA Novis BH Bank S Wormold L Jacobs P Serum lysozyme in Crohn's disease and ulcerative colitis.S Afr Med J. 1977; 52: 1042-1044PubMed Google Scholar, 18Jensen KB Jarnum S Koudahl G Kristensen M Serum orosomucoid in ulcerative colitis: its relation to clinical activity, protein loss, and turnover of albumin and IgG.Scand J Gastroenterol. 1976; 11: 177-183PubMed Google Scholar, 19Cooke WT Fowler DI Cox EV Gaddie R Meynell MJ The clinical significance of seromucoids in regional ileitis and ulcerative colitis.Gastroenterology. 1958; 34: 910-919PubMed Scopus (32) Google Scholar, 20Adeyemi EO Neumann S Chadwick VS Hodgson HJF Pepys MB Circulating human leucocyte elastase in patients with inflammatory bowel disease.Gut. 1985; 26: 1306-1311Crossref PubMed Scopus (60) Google Scholar, 21Fiasse R Lurhuma AZ Cambiaso CL Masson PL Dive C Circulating immune complexes and disease activity in Crohn's disease.Gut. 1978; 19: 611-617Crossref PubMed Scopus (34) Google Scholar, 22Das KM Kadono Y Fleischner GM Antibody-dependent cell-mediated cytotoxicity in serum samples from patients with ulcerative colitis: relationship to disease activity and response to total colectomy.Am J Med. 1984; 77: 791-796Abstract Full Text PDF PubMed Scopus (26) Google Scholar, 23Niederwieser D Fuchs D Hausen A Judmaier G Reibnegger G Wachter H Huber C Neopterin as a new biochemical marker in the clinical assessment of ulcerative colitis.Immunobiology. 1985; 170: 320-326Crossref PubMed Scopus (52) Google Scholar, 24Reibnegger G Bollbach R Fuchs D Hausen A Judmaier G Prior C Rotthauwe HW Werner ER Wachter H A simple index relating clinical activity in Crohn's disease with T cell activation: hematocrit, frequency of liquid stools and urinary neopterin as parameters.Immunobiology. 1986; 173: 1-11Crossref PubMed Scopus (26) Google Scholar, 25Rhodes JM Gallimore R Elias E Allan RN Kennedy JF Faecal mucus degrading glycosidases in ulcerative colitis and Crohn's disease.Gut. 1985; 26: 761-765Crossref PubMed Scopus (44) Google Scholar, 26Rhodes JM Gallimore R Elias E Kennedy JF Faecal sulphatase in health and in inflammatory bowel disease.Gut. 1985; 26: 466-469Crossref PubMed Scopus (13) Google Scholar, 27Meyers S Wolke A Field SP Feuer EJ Johnson JW Janowitz HD Fecal α1-antitrypsin measurement: an indicator of Crohn's disease activity.Gastroenterology. 1985; 89: 13-18PubMed Google Scholar, 28Grill BB Hillemeier AC Gryboski JD Fecal α1-antitrypsin clearance in patients with inflammatory bowel disease.J Pediatr Gastroenterol Nutr. 1984; 3: 56-61Crossref PubMed Scopus (41) Google Scholar, 29Ehsanullah M Filipe MI Gazzard B Mucin secretion in inflammatory bowel disease: correlation with disease activity and dysplasia.Gut. 1982; 23: 485-489Crossref PubMed Scopus (77) Google Scholar, 30Thompson JS Burnett DA Markin RS Vaughan WP Intestinal mucosa diamine oxidase activity reflects intestinal involvement in Crohn's disease.Am J Gastroenterol. 1988; 83: 756-760PubMed Google Scholar The fact that so many indices have been proposed suggests that none is optimal.Table 3Laboratory Measurements Proposed for Assessment of Disease Activity in Inflammatory Bowel DiseaseMeasurementReferencePlasma Erythrocyte sedimentation rateSachar et al12Sachar DB Smith H Chan S Cohen LB Lichtiger S Messer J Erythrocyte sedimentation rate as a measure of clinical activity in inflammatory bowel disease.J Clin Gastroenterol. 1986; 8: 647-650Crossref PubMed Scopus (73) Google Scholar Serum amyloid A proteinChambers et al13Chambers RE Stross P Barry RE Whicher JT Serum amyloid A protein compared with C-reactive protein, alpha 1-antichymotrypsin and alpha 1-acid glycoprotein as a monitor of inflammatory bowel disease.Eur J Clin Invest. 1987; 17: 460-467Crossref PubMed Scopus (70) Google Scholar C-reactive proteinFagan et al14Fagan EA Dyck RF Maton PN Hodgson HJF Chadwick VS Petrie A Pepys MB Serum levels of C-reactive protein in Crohn's disease and ulcerative colitis.Eur J Clin Invest. 1982; 12: 351-359Crossref PubMed Scopus (246) Google ScholarAndré et al15André C Descos L Vignal J Gillon J C-reactive protein as a predictor of relapse in asymptomatic patients with Crohn's disease.Scott Med J. 1983; 28: 26-29PubMed Google Scholar α1-Acid glycoproteinDearing et al16Dearing WH McGuckin WF Elveback LR Serum α1acid glycoprotein in chronic ulcerative colitis.Gastroenterology. 1969; 56: 295-303PubMed Scopus (31) Google Scholar LysozymeHelman et al17Helman CA Novis BH Bank S Wormold L Jacobs P Serum lysozyme in Crohn's disease and ulcerative colitis.S Afr Med J. 1977; 52: 1042-1044PubMed Google Scholar OrosomucoidJensen et al18Jensen KB Jarnum S Koudahl G Kristensen M Serum orosomucoid in ulcerative colitis: its relation to clinical activity, protein loss, and turnover of albumin and IgG.Scand J Gastroenterol. 1976; 11: 177-183PubMed Google Scholar SeromucoidsCooke et al19Cooke WT Fowler DI Cox EV Gaddie R Meynell MJ The clinical significance of seromucoids in regional ileitis and ulcerative colitis.Gastroenterology. 1958; 34: 910-919PubMed Scopus (32) Google Scholar Leukocyte elastaseAdeyemi et al20Adeyemi EO Neumann S Chadwick VS Hodgson HJF Pepys MB Circulating human leucocyte elastase in patients with inflammatory bowel disease.Gut. 1985; 26: 1306-1311Crossref PubMed Scopus (60) Google Scholar Immune complexesFiasse et al21Fiasse R Lurhuma AZ Cambiaso CL Masson PL Dive C Circulating immune complexes and disease activity in Crohn's disease.Gut. 1978; 19: 611-617Crossref PubMed Scopus (34) Google Scholar Antibody-dependent cell-mediated cytotoxicityDas et al22Das KM Kadono Y Fleischner GM Antibody-dependent cell-mediated cytotoxicity in serum samples from patients with ulcerative colitis: relationship to disease activity and response to total colectomy.Am J Med. 1984; 77: 791-796Abstract Full Text PDF PubMed Scopus (26) Google ScholarUrine NeopterinNiederwieser et al23Niederwieser D Fuchs D Hausen A Judmaier G Reibnegger G Wachter H Huber C Neopterin as a new biochemical marker in the clinical assessment of ulcerative colitis.Immunobiology. 1985; 170: 320-326Crossref PubMed Scopus (52) Google ScholarReibnegger et al24Reibnegger G Bollbach R Fuchs D Hausen A Judmaier G Prior C Rotthauwe HW Werner ER Wachter H A simple index relating clinical activity in Crohn's disease with T cell activation: hematocrit, frequency of liquid stools and urinary neopterin as parameters.Immunobiology. 1986; 173: 1-11Crossref PubMed Scopus (26) Google ScholarFeces Mucus-degrading glycosidasesRhodes et al25Rhodes JM Gallimore R Elias E Allan RN Kennedy JF Faecal mucus degrading glycosidases in ulcerative colitis and Crohn's disease.Gut. 1985; 26: 761-765Crossref PubMed Scopus (44) Google Scholar SulfataseRhodes et al26Rhodes JM Gallimore R Elias E Kennedy JF Faecal sulphatase in health and in inflammatory bowel disease.Gut. 1985; 26: 466-469Crossref PubMed Scopus (13) Google Scholar α1-AntitrypsinMeyers et al27Meyers S Wolke A Field SP Feuer EJ Johnson JW Janowitz HD Fecal α1-antitrypsin measurement: an indicator of Crohn's disease activity.Gastroenterology. 1985; 89: 13-18PubMed Google ScholarGrill et al28Grill BB Hillemeier AC Gryboski JD Fecal α1-antitrypsin clearance in patients with inflammatory bowel disease.J Pediatr Gastroenterol Nutr. 1984; 3: 56-61Crossref PubMed Scopus (41) Google ScholarTissue MucinEhsanullah et al29Ehsanullah M Filipe MI Gazzard B Mucin secretion in inflammatory bowel disease: correlation with disease activity and dysplasia.Gut. 1982; 23: 485-489Crossref PubMed Scopus (77) Google Scholar Diamine oxidaseThompson et al30Thompson JS Burnett DA Markin RS Vaughan WP Intestinal mucosa diamine oxidase activity reflects intestinal involvement in Crohn's disease.Am J Gastroenterol. 1988; 83: 756-760PubMed Google Scholar Open table in a new tab The best-known laboratory indices are (1) the nonspecific acute phase reactants, such as erythrocyte sedimentation rate, C-reactive protein, and orosomucoid, and (2) measures of increased intestinal permeability, such as fecal α1-antitrypsin. Several studies have reached different conclusions about the reliability of using the erythrocyte sedimentation rate to assess the severity of disease activity in inflammatory bowel disease. A strong correlation between the erythrocyte sedimentation rate and disease activity in both ulcerative colitis and Crohn's disease was reported by Talstad and Gjone.31Talstad I Gjone E The disease activity of ulcerative colitis and Crohn's disease.Scand J Gastroenterol. 1976; 11: 403-408PubMed Google Scholar Similarly, van Hees and colleagues9Van Hees PAM van Elteren PH van Lier HJJ van Tongeren JHM An index of inflammatory activity in patients with Crohn's disease.Gut. 1980; 21: 279-286Crossref PubMed Scopus (313) Google Scholar found a good correlation between the erythrocyte sedimentation rate and disease activity in Crohn's disease and included it in their activity index. In contrast, several other investigators have found no correlation between erythrocyte sedimentation rate and disease activity assessed clinically14Fagan EA Dyck RF Maton PN Hodgson HJF Chadwick VS Petrie A Pepys MB Serum levels of C-reactive protein in Crohn's disease and ulcerative colitis.Eur J Clin Invest. 1982; 12: 351-359Crossref PubMed Scopus (246) Google Scholar, 32Cooke WT Prior P Determining disease activity in inflammatory bowel disease.J Clin Gastroenterol. 1984; 6: 17-25PubMed Google Scholar or endoscopically.33Powell-Tuck J Day DW Buckell NA Wadsworth J Lennard-Jones JE Correlations between defined sigmoidoscopic appearances and other measures of disease activity in ulcerative colitis.Dig Dis Sci. 1982; 27: 533-537Crossref PubMed Scopus (177) Google Scholar Because some studies found no correlation between erythrocyte sedimentation rate and evidence of small bowel involvement in Crohn's disease or rectal inflammation in ulcerative colitis,12Sachar DB Smith H Chan S Cohen LB Lichtiger S Messer J Erythrocyte sedimentation rate as a measure of clinical activity in inflammatory bowel disease.J Clin Gastroenterol. 1986; 8: 647-650Crossref PubMed Scopus (73) Google Scholar, 34Prantera C Luzi C Olivotto P Levenstein S Cerro P Fanucci A Relationship between clinical and laboratory parameters and length of lesion in Crohn's disease of small bowel.Dig Dis Sci. 1984; 29: 1093-1097Crossref PubMed Scopus (35) Google Scholar the erythrocyte sedimentation rate seems to be a more useful factor in patients with colonic inflammation (ulcerative colitis or Crohn's disease) that extends beyond the rectum and sigmoid. As with other acute phase serum proteins, the concentration of C-reactive protein is increased in inflammatory bowel disease. Fagan and colleagues14Fagan EA Dyck RF Maton PN Hodgson HJF Chadwick VS Petrie A Pepys MB Serum levels of C-reactive protein in Crohn's disease and ulcerative colitis.Eur J Clin Invest. 1982; 12: 351-359Crossref PubMed Scopus (246) Google Scholar demonstrated that serum C-reactive protein was significantly increased in patients with Crohn's disease and correlated well with the CDAI.6Best WR Becktel JM Singleton JW Kern Jr, F Development of a Crohn's disease activity index: National Cooperative Crohn's Disease Study.Gastroenterology. 1976; 70: 439-444Abstract Full Text PDF PubMed Scopus (3020) Google Scholar Unlike other acute phase reactants, C-reactive protein responds more rapidly to an acute insult and with large incremental changes. Such properties would suggest that C-reactive protein is a more precise laboratory marker of disease activity than other indices. The actual level of C-reactive protein, however, seems to have little predictive value in terms of the severity of inflammatory activity assessed by CDAI.14Fagan EA Dyck RF Maton PN Hodgson HJF Chadwick VS Petrie A Pepys MB Serum levels of C-reactive protein in Crohn's disease and ulcerative colitis.Eur J Clin Invest. 1982; 12: 351-359Crossref PubMed Scopus (246) Google Scholar In most cases, fluctuations in serial measurements of acute phase reactants in serum provide confirmatory information about the patient's clinical status. In certain instances, however, the clinical and laboratory assessments of intestinal inflammation do not parallel each other, and a low level of a single laboratory index may occur in a patient with a high clinical activity score as a result of abdominal pain caused by fibrotic obstruction. Conversely, changes in such reactants are not specific for bowel inflammation, and high levels of a single laboratory measurement in conjunction with a low clinical activity score may be seen in patients with inflammation unrelated to intestinal disease. In summary, although single laboratory measurements are useful in confirming the clinical assessment of disease activity and in monitoring the response to therapy, they cannot alone establish the severity of intestinal inflammation. Advances in radiologic techniques, such as the introduction of double-contrast colon roentgenography35Williams Jr, HJ Stephens DH Carlson HC Double-contrast radiography: colonic inflammatory disease.AJR. 1981; 137: 315-322Crossref PubMed Scopus (17) Google Scholar and small bowel enteroclysis,36Ekberg O Crohn's disease of the small bowel examined by double contrast technique: a comparison with oral technique.Gastrointest Radiol. 1977; 1: 355-359Crossref PubMed Scopus (40) Google Scholar, 37Nolan DJ Cadman PJ The small bowel enema made easy.Clin Radiol. 1987; 38: 295-301Abstract Full Text PDF PubMed Scopus (30) Google Scholar, 38Maglinte DDT Lappas JC Kelvin FM Rex D Chernish SM Small bowel radiography: how, when, and why?.Radiology. 1987; 163: 297-305Crossref PubMed Scopus (107) Google Scholar have dramatically improved the potential for detection of superficial lesions and assessment of disease activity and extent in inflammatory bowel disease.35Williams Jr, HJ Stephens DH Carlson HC Double-contrast radiography: colonic inflammatory disease.AJR. 1981; 137: 315-322Crossref PubMed Scopus (17) Google Scholar Fluoroscopy of the small intestine in conjunction with vigorous manual palpation is still a sensitive method of detecting Crohn's disease.39Carlson HC Perspective: the small bowel examination in the diagnosis of Crohn's disease.AJR. 1986; 147: 63-65Crossref PubMed Scopus (47) Google Scholar Hence, studies in which radiology has been compared with endoscopy in the assessment of inflammatory bowel disease40Hogan WJ Schmitt MG Wu WC Geenen JE The role of colonoscopy in assessing the presence, extent and severity of chronic inflammatory bowel disease (CIBD) (abstract).Gastroenterology. 1974; 66: 814Google Scholar, 41Gabrielsson N Granqvist S Sundelin P Thorgeirsson T Extent of inflammatory lesions in ulcerative colitis assessed by radiology, colonoscopy, and endoscopic biopsies.Gastrointest Radiol. 1979; 4: 395-400Crossref PubMed Scopus (39) Google Scholar, 42Williams C Evaluation of the colonoscopic examination: results of three studies.Dis Colon Rectum. 1975; 18: 366-368Crossref PubMed Scopus (14) Google Scholar, 43Farmer RG Whelan G Sivak Jr, MV Colonoscopy in distal colon ulcerative colitis.Clin Gastroenterol. May 1980; 9: 297-306PubMed Google Scholar are less relevant today than they were a decade ago, when comparisons were made chiefly with single-contrast studies. Nevertheless, the wide applicability and ease with which endoscopic assessment of the stomach, duodenum, distal ileum, and colon can be done, as well as the abi
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