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© Borgis - Postępy Nauk Medycznych 3/2014, s. 181-185
*Edyta Szymańska1, Jarosław Kierkuś2
Monitorowanie aktywności choroby Crohna: skala kliniczna, endoskopowa oraz histologiczna
Monitoring Crohn’s disease activity: clinical, endoscopic and histological indices
1Department of Pediatrics, Nutrition and Metabolic Disorders, Children’s Memorial Health Institute, Warszawa
Head of Departament: prof. Janusz Książyk
2Department of Gastroenterology, Hepatology and Feeding Disorders, Children’s Memorial Health Institute, Warszawa
Head of Department: prof. Józef Ryżko, MD, PhD
Streszczenie
Choroba Crohna (ang. Crohn’s disease – CD) razem z wrzodziejącym zapaleniem jelita grubego (ang. ulcerative colitis – UC) należą do grupy nieswoistych chorób zapalnych jelit (ang. nflammatory bowel disease – IBD). Przebieg kliniczny obydwu chorób jest podobny i charakteryzuje się okresami zaostrzeń oraz remisji, jednak ich obraz histopatologiczny różni się między sobą. Ponadto, obraz mikroskopowy odzwierciedla stopień aktywności choroby i jest wykorzystywany do monitorowania przebiegu IBD. Jednak, w przypadku CD obraz endoskopowy nie zawsze oddaje wszystkie cechy charakterystyczne choroby. W ostatnim czasie pojawiło się wiele swoistych dla CD parametrów, zwłaszcza kompleksowych numerycznych skal służących do oceny aktywności choroby. Dlatego też całościowa ocena kliniczna, endoskopowa i histologiczna są niezbędne zarówno do postawienia rozpoznania, jak i do śledzenia przebiegu IBD, a także do różnicowania CD i UC od innych jednostek chorobowych. Celem artykułu jest omówienie dostępnych skal oceny klinicznej, endoskopowej i histologicznej IBD wykorzystywanych w praktyce klinicznej.
Summary
Crohn’s disease (CD) together with ulcerative colitis (UC) belong to chronic gastrointestinal condition called inflammatory bowel disease (IBD). The clinical course of both disorders is similar and is characterized by exacerbations and spontaneous or drug-induced remissions but their histopathological features are different. Moreover, the various clinical patterns are reflected in the microscopic features observed in biopsies obtained during endoscopy, which is used for monitoring of disease activity. However, endoscopic mucosal biopsies do not show all the characteristic features of CD. In the last years, many disease-specific instruments, especially complex numeric activity indices to measure activity have been created. Therefore, the review of biopsies, in combination with clinical, laboratory, radiographic and endoscopic observations, is needed for both diagnosis and monitoring of IBD, and for the differentiation CD and UC from other conditions. The aim of this article is to make a revision of available clinical, endoscopic and histopathological scales used in common practice for diagnosis and monitoring of CD.



Introduction
Crohn’s disease (CD) and ulcerative colitis (UC) belong to chronic gastrointestinal condition called inflammatory bowel disease (IBD). The clinical course of both disorders is similar and their most common symptoms are abdominal pain, diarrhea, often with bloody stools and malnutrition, typical for pediatric population (1). IBD is characterized by exacerbations and spontaneous or drug-induced remissions. However, the histopathological features are different whether CD or UC. UC primarily affects the mucosa of the large bowel, while CD is a transmural disease that can affect the whole gastrointestinal tract (2). Moreover, the various clinical patterns are reflected in the microscopic features observed in biopsies obtained during endoscopy, which is used for monitoring of disease activity. Therefore, biopsies allow assessment of disease activity but also identification of pre-cancerous lesions and cancer, which apply rather to adult patients than pediatric population. In CD, in contrast with UC, the rectum is not always involved and lesions in this type of IBD frequently occur in a background of normal mucosa (3). Thus, it is more appropriate to take multiple endoscopic biopsies in different segments of the colon (and ileum) during both initial work-up of a patient and while monitoring treatment efficacy (4). However, endoscopic mucosal biopsies do not show all the characteristic features of CD. Therefore, the review of biopsies, in combination with clinical, laboratory, radiographic and endoscopic observations, is needed for both diagnosis and monitoring of IBD, and for the differentiation CD and UC from other conditions. In the last years, many disease-specific instruments, especially complex numeric activity indices to measure activity have been created (5). Objective measures of activity in CD are very useful not only in everyday work but also in clinical trials to enroll homogeneous groups of patients and to evaluate their response treatment. Therefore, in order to be widely used, activity indices should be simple and easily reproducible. In this article, we make a revision of available clinical, endoscopic and histopathological scales used in common practice for diagnosis and monitoring of CD.
Clinical activity scores
There have been few activity indices proposed so far: the Simple index (or Harvey Bradshaw index) (6), the Organization Mondiale de Gastroenterologie (OMGE) index (7), the Cape Town index (8) and Crohn’s Disease Activity Index (CDAI) (9) with its pediatric version – PCDAI (10). However, only the last two are widely used in clinical practice. The CDAI was developed by Best et al. from the Midwest Regional Health Center in Illinois, in 1976 (9). The index consists of eight factors, each summed after adjustment with a weighting factor. The components of the CDAI and weighting factors are collected in table 1.
Table 1. The components of the CDAI and weighting factors.
Clinical or laboratory variableWeighting factor
Number of liquid or soft stools each day for seven daysx 2
Abdominal pain (graded from 0-3 on severity) each day for seven daysx 5
General well being, subjectively assessed from 0 (well) to 4 (terrible) each day for seven daysx 7
Presence of complications*x 20
Taking Lomotil or opiates for diarrheax 30
Presence of an abdominal mass (0 as none, 2 as questionable, 5 as definite)x 10
Hematocrit of < 0.47 in men and < 0.42 in womenx 6
Percentage deviation from standard weightx 1
*One point each is added for each set of complications:
– the presence of joint pains (arthralgia) or frank arthritis
– inflammation of the iris or uveitis
– presence of erythema nodosum, pyoderma gangrenosum, or aphthous ulcers
– anal fissures, fistulae or abscesses
– other fistulae
– fever during the previous week

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Piśmiennictwo
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otrzymano: 2013-12-20
zaakceptowano do druku: 2014-02-06

Adres do korespondencji:
*Edyta Szymańska
Department of Pediatrics, Nutrition and Metabolic Disorders
Children’s Memorial Health Institute
Al. Dzieci Polskich 20, 04-730 Warszawa
tel. +48 513-017-570
e.szymanska@czd.pl

Postępy Nauk Medycznych 3/2014
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