(UCEIS) has recently been proposed (Table 7) (38). This score incorporates 3 items—vascular pattern, bleeding, and erosions and ulcers, quantifying each on a scale of 0–3 (0–2 for vascular pattern) for a total score ranging between 0 and 8. The UCEIS demonstrated excellent correlation with disease severity (60) and good intra- and inter-observer reliability (60,61). Preliminary data suggest that this score is also responsive to therapy, and improvement with treatment predicts medium- and long-term outcomes (62). Table 4 summarizes the different parameters used in this guideline for the purpose of defining mildly active and moderately to severely active UC (44,63). Figure 1 shows representative endoscopic photographs comparing the traditional Mayo endoscopic subscore and the UCEIS. UC is also associated with psychosocial and economic disruption and disability. There are ongoing efforts to quantify such disability through validated indexes that correlate well with disease severity and QoL (63–65). There are insufficient data to recommend the routine use of such scores in clinical practice. However, it is important to include assessments of the impact of the disease on the patients' lives in the determination of overall severity and selection of the appropriate treatment algorithm. Evaluation of UC during relapses should include assessment of severity of symptoms and potential triggers, including enteric infections (particularly C. diff), NSAID use, and recent smoking cessation. Nonadherence to therapy is common in patients with UC and is associated with an increased risk of relapse and cost of care (66,67). UC is an evolving disease, and the risk of disease extension should be kept in mind in individuals with initially localized disease, particularly with nonresponse to topical treatment. Up to 46% of patients with proctitis and 70% with left-sided colitis may develop extensive colitis on follow-up (68). It is important to recognize that endoscopic evaluation in individuals with loss of response may reveal patchiness of endoscopic and histologic activity including an appearance of relative rectal sparing with the use of topical treatments. A comprehensive assessment of severity of UC should include predictors of an aggressive disease course, need for colectomy, and response to therapies. Several prospective cohorts have examined the role of clinical parameters, genetics, and serologic markers in predicting the need for colectomy in UC (69,70). Extensive colitis, need for systemic steroids, young age at diagnosis, and elevated CRP or ESR are associated with higher rates of colectomy (69,71). Patients with a previous hospitalization for their UC are also at a higher risk of subsequent colectomy (72). The yield of genetic or serologic markers in predicting severity and course of UC has been modest at best, and their use cannot be recommended in routine clinical practice based on available data (40,41). Table 8 summarizes the factors associated with an increased risk of colectomy and a poor prognosis (3). GOALS FOR MANAGING PATIENTS WITH ULCERATIVE COLITIS Key concept statements 8. UC is a chronic condition for which therapy is required to induce and maintain remission; therapeutic decisions should be categorized into those for (i) induction and (ii) maintenance, with a goal of obtaining and maintaining a steroid-free remission. 9. Strategies for management of UC should reflect the patient's and provider's goals and recognize the chronic nature of the disease. 10.