Criteria
Endoscopic findings[4]
Three major endoscopic findings are supportive of the diagnosis of Crohn disease (CD).
Aphthous ulcers - small, discrete aphthous ulcers can be seen in early lesions. These progress to involve the entire wall of the bowel and can course for several centimeters.
Cobblestoning - normal tissues in between the ulcers give the typical cobblestone appearance.
Discontinuous lesions - areas of inflammation are interspersed between normal bowel "skip areas."
Endoscopic scoring systems[100][101][102][103]
Endoscopic scoring systems include the Crohn Disease Endoscopic Index of Severity (CDEIS) and the Simple Endoscopic Score for Crohn Disease (SES-CD).
CDEIS is an index for determining the severity of CD with endoscopic localization to ileum and colon. The CDEIS score ranges from 0-44, with higher scores indicating more severe disease. The score includes four parameters:
Deep ulceration (12 if present, 0 if absent)
Superficial ulceration (6 if present, 0 if absent)
Length of diseased mucosa 0-10 cm (score 0-10 according to length in cm)
Length of ulcerated mucosa 0-10 cm (score 0-10 according to length in cm)
Each parameter is evaluated in five predefined segments of the colon (ileum, ascending colon, transverse colon, descending colon and sigmoid loop, and rectum). The numbers are all added in each segment and divided by the number of segments evaluated. Additional points are given for ulcerated and nonulcerated stenosis (0 if absent, 3 if present).
A score of under 3 indicates remission, 3-8 indicates mild endoscopic activity, 9-12 indicates moderate endoscopic activity, and a score of over 12 indicates severe endoscopic activity.
SES-CD was developed as an alternative to CDEIS (which is complicated and time consuming and not, therefore, routinely used in clinical practice). A score of 56 is the maximum possible score, and higher scores indicate more severe disease.
Size of mucosal ulcers (none = 0, aphthous [0.1 to 0.5 cm] = 1, large [0.5 to 2 cm] = 2, very large [>2 cm] = 3)
Surface involved by disease (0% = 0, <50% = 1, 50% to 75% = 2, >75% = 3)
Surface involved by ulceration (0% = 0, <10% = 1, 10% to 30% = 2, >30% = 3)
Narrowings (none = 0, single can be passed = 1, multiple can be passed = 2, cannot be passed = 3)
A score of 0 to 2 indicates remission, a score of 3 to 6 indicates mild endoscopic activity, a score of 7 to 15 indicates moderate endoscopic activity, a score of >15 indicates severe endoscopic activity.
Clinical scoring systems[104][105]
Clinical scoring systems include the Crohn Disease Activity Index (CDAI) and the Harvey-Bradshaw Index (HBI).
CDAI[104]
Eight factors, each summed after a weighting score:
Number of liquid or soft stools each day for 7 days x2
Abdominal pain (graded from 0-3 on severity) each day for 7 days x5
General wellbeing, subjectively assessed from 0 (well) to 4 (terrible) each day for 7 days x7
Presence of complications, 1 point for each x20:
Arthralgia or arthritis
Iritis or uveitis
Presence of erythema nodosum, pyoderma granulosum, or aphthous ulcers
Anal fissures, fistulae, or abscesses
Other fistulae
Fever during the past 7 days
Taking antidiarrheal drugs x30
Presence of an abdominal mass (0 as none, 2 as questionable, 5 as definite) x10
Hematocrit <0.47 in men and <0.42 in women x6
Percentage deviation from standard weight x1
Index values of 150 and below are associated with quiescent disease; values above that indicate active disease, and values above 450 are seen with extremely severe disease.
HBI[105]
The HBI is a simplified version of the CDAI to collect clinical data related to CD.
The index includes five parameters:
Patient well-being for the previous day (very well = 0, slightly below par = 1, poor = 2, very poor = 3, terrible = 4)
Abdominal pain for the previous day (none = 0, mild = 1, moderate = 2, severe = 3)
Number of liquid or soft stools for the previous day
Abdominal mass (none = 0, dubious = 1, definite = 2, definite and tender = 3)
Complications (none = 0, yes = 1 point for each: arthralgia, uveitis, erythema nodosum, aphthous ulcer, pyoderma gangrenosum, anal fissures, appearance of a new fistula, abscess)
A score of <5 indicates remission, a score of 5 to 7 indicates mild activity, a score of 8 to 16 indicates moderate activity, and a score of >16 indicates severe activity.
European Crohn's and Colitis Organisation (ECCO) and American College of Gastroenterology clinical severity classification[71][106]
Mild disease: ambulatory and able to tolerate oral alimentation without manifestations of dehydration, systemic toxicity (high fevers, rigors, and prostration), abdominal tenderness, painful mass, intestinal obstruction, or >10% weight loss. It is equivalent to a CDAI of between 150 and 220.
Moderate disease: failure of response to treatment for mild disease, or with more prominent symptoms of fever, significant weight loss >10%, abdominal pain or tenderness, intermittent nausea or vomiting (without obstructive findings), or significant anemia. It is equivalent to a CDAI of between 220 and 450.
Severe disease: persistent symptoms despite the introduction of intensive treatment (e.g., the use of corticosteroids or biologic agents [e.g., infliximab, adalimumab]) or evidence of intestinal obstruction or abscess formation (with significant peritoneal signs, such as involuntary guarding or rebound tenderness), or cachexia (BMI <18 kg/m²). C-reactive protein is increased. It is equivalent to a CDAI of >450.
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