Disease Activity Score and Classification

Because of the great variability in the results of reports on the incidence of pouchitis and in the assessment of therapy due to the lack of standardised diagnostic criteria, Sandborn and colleagues developed a pouchitis disease activity index (PDAI). This 18-point index, calculated via three separate 6-point scales based on clin ical symptoms, endoscopic appearance and histologic findings, represents an objective and reproducible scoring system for pouchitis [26]. Active pouchitis is defined by a total PDAI score >7 and remission is defined as a score <7. Once diagnosis is made, pouchitis can be further classified. The disease activity can be defined as remission, mild-moderate (increased stool frequency, urgency, infrequent incontinence) or severe (dehydration, frequent incontinence). Pouchi-tis can also be defined on the basis of the duration of disease: acute (<4 weeks) or chronic (>4 weeks). Another way to classify this syndrome considers the following patterns: infrequent (a single or two acute episodes), relapsing (more than three acute episodes) in about two thirds of cases, continuous or chronic disease (a treatment responsive form requiring a maintenance therapy or a treatment-resistant form). About 15% of patients have a chronic disease and some of them require surgical excision or exclusion of the pouch because of impairment of reservoir function and poor quality of life.

The PDAI, nowadays, is the most frequently used scoring system in clinical studies to determine pou-chitis disease activity. The validity of PDAI and the necessity of its application in epidemiological, patho-physiological or clinical studies, as well as in clinical practice in order to make a correct diagnosis of pouchitis, have been shown by Shen et al. [27] in a study evaluating the correlation between symptoms, endoscopy and histologic findings in patients with IPAA for UC. They found that symptoms alone do not reliably diagnose pouchitis, whereas an evaluation including symptoms, endoscopy and histology is the best way to make the diagnosis. In fact, 25% of patients with a high symptom score did not, in any of the cases, reach the PDAI diagnostic criteria and 36% of patients with minimal symptoms achieved a PDAI score ^7 because of significant endoscopic and histologic inflammation [27].

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