Subsequent endoscopic indices of increasing complexity incorporated the presence of ulcers, mucopus, granularity, and appearance of light find more scattering, in addition to bleeding and friability. Such modifications

were intended to improve the capture of disease activity, but they invariably increased the subjectivity of the scoring system. Table 1 summarizes commonly used endoscopic indices for UC, none of which have been validated with the exception of the UCEIS.31 Nonetheless, there is no agreed threshold for defining either mucosal healing or endoscopic remission, which makes it almost impossible to compare mucosal healing rates between studies.33 Space does not allow a review of all indices, so this article focuses on the Mayo Clinic endoscopy

subscore, because this is commonly used in clinical trials, and the UCEIS, which has been validated. The Mayo Clinic endoscopy subscore has 4 components, with a maximum total score of 3 (Table 2).26 There is overlap in the features of the different levels of this endoscopic index, which causes high interobserver variation. The most troublesome component of this index is friability, as this is subjective and leads to inconsistent results.34 This inconsistency has lead to an adaptation of the index to remove friability from level 1.35 The value of this index lies KU-60019 research buy with its widespread use in clinical trials. In trials of infliximab and adalimumab, mucosal healing was defined as a Mayo subscore of 0 or 1 or a decrease from the baseline subscores of 2 or 3. In Active Ulcerative Colitis Trials, patients with a posttreatment Mayo score of grade 1 were no more likely to undergo a colectomy than those with a score of 0.36 The UCEIS (Table 3)

was developed because of wide interobserver variation in endoscopic assessment of disease activity.31 There was only 76% agreement for severe and 27% agreement for normal endoscopic mucosal appearances between 10 experienced investigators and a central reader. Thirty different investigators then rated 25/60 different videos for 10 descriptors and assessed overall severity on a 0 to 100 visual analog scale. Kappa statistics tested interobserver and intraobserver variability for each descriptor. Different models to predict the overall assessment of severity as judged by a visual analog Histamine H2 receptor scale were developed using general linear mixed regression. The final model incorporated just 3 descriptors, each with precise definitions. A third validation phase used another 25 different investigators from North America and Europe, who assessed in a randomly selected subset of 28/60 videos, including 2 duplicated videos to assess test-retest reliability. Intraobserver kappa values were 0.82, 0.72, and 0.78 for vascular pattern, bleeding, and erosion and ulcer descriptors, and interobserver kappa values were 0.83, 0.56, and 0.77, respectively.