Ulcerative colitis hub
Monitoring UC Over Time
Last Updated Nov 11, 2025
Ulcerative colitis requires steady, structured follow‑up. Monitoring tracks symptoms, stool and blood biomarkers, and, at key times, colonoscopy results. The aim is remission that lasts, not short bursts of relief. Good monitoring also lowers colorectal cancer risk by catching precancerous changes early. This guide outlines remission targets, how to use biomarkers, and when dysplasia surveillance colonoscopies are due.
Key takeaways
Treat‑to‑target in UC aims for clinical remission, normal biomarkers, and endoscopic healing, with histologic healing as an adjunct goal. (pubmed.ncbi.nlm.nih.gov)
In stable remission, stool biomarkers every 6–12 months can safely reduce routine scoping when results are normal. Fecal calprotectin under 150 µg/g helps rule out active inflammation. (gastro.org)
After therapy changes, an early fecal calprotectin check around 8–12 weeks helps gauge response and predict later outcomes. (pubmed.ncbi.nlm.nih.gov)
Endoscopic healing with a Mayo endoscopic subscore of 0 is linked to fewer relapses than a score of 1. (bmcgastroenterol.biomedcentral.com)
Start dysplasia surveillance 8–10 years after colitis onset if disease extends beyond the rectum. Use risk‑stratified intervals of 1, 2–3, or 5 years. Annual from diagnosis if primary sclerosing cholangitis is present. (gastro.org)
What “remission” means in UC
Treat‑to‑target care sets clear goals and checks progress regularly.
Clinical remission: no rectal bleeding and normal stool frequency.
Biomarker remission: normal C‑reactive protein (CRP) and low fecal calprotectin.
Endoscopic remission: a normal‑appearing mucosa. For UC, a Mayo endoscopic subscore (MES) of 0 is preferred.
Histologic remission: no active inflammation on biopsy. This is supportive, not a formal universal target, but it adds depth to remission. (pubmed.ncbi.nlm.nih.gov)
Targets at a glance
Domain | How it is measured | Practical target |
|---|---|---|
Symptoms | Bleeding, urgency, stool frequency | None or minimal symptoms |
Stool biomarkers | Fecal calprotectin | Under 150 µg/g in remission |
Blood biomarkers | CRP | In the lab’s normal range |
Endoscopy | MES or UCEIS score | MES 0 preferred |
Histology | Nancy or Geboes score | No neutrophils, “inactive” pattern |
MES 0 is linked to lower relapse risk than MES 1, so teams often aim for 0 when possible. (bmcgastroenterol.biomedcentral.com)
Biomarker monitoring: what to check and when
Biomarkers help separate true inflammation from look‑alike symptoms such as irritable bowel syndrome or hemorrhoids. They also guide when a scope is needed.
Fecal calprotectin is the most informative day‑to‑day marker. In people with UC who feel well, a value under 150 µg/g helps rule out active inflammation and supports avoiding routine endoscopy. If elevated, endoscopic assessment is advised rather than empiric medication changes. (gastro.org)
CRP is helpful, although it can be less sensitive in UC than in Crohn’s disease. Use it alongside stool tests.
Suggested rhythms
After starting or changing therapy: recheck fecal calprotectin around 8–12 weeks. Week‑8 values predict later mucosal healing and long‑term outcomes in multiple cohorts. Values at or below 150–250 µg/g after induction are associated with better odds of endoscopic and histologic remission at one year. (pubmed.ncbi.nlm.nih.gov)
In stable remission: monitor biomarkers every 6–12 months, sooner if new symptoms or a rising trend appears. Normal results support continuing current therapy without routine scoping. (gastro.org)
Common tests and typical use
Test | What it shows | When it is useful |
|---|---|---|
Fecal calprotectin | Neutrophil activity in the gut | Every 6–12 months in remission, and about 8–12 weeks after treatment changes |
Fecal lactoferrin | Alternative stool marker of inflammation | When calprotectin is not available or to confirm a rise |
CRP | Systemic inflammation | With stool markers, during flares, and for trends over time |
Endoscopic follow‑up: confirming healing
Endoscopy confirms whether the lining has healed and guides major treatment decisions. In UC, aiming for MES 0 reduces the risk of relapse compared with MES 1. Teams often schedule a confirmation scope within the first year after major therapy changes or sooner if biomarkers rise or symptoms persist. (bmcgastroenterol.biomedcentral.com)
Dysplasia and colorectal cancer surveillance
Who needs surveillance
Extensive or left‑sided colitis: begin colonoscopic surveillance 8–10 years after colitis onset, then repeat at risk‑based intervals. Proctitis alone follows average‑risk national screening. (gastro.org)
Primary sclerosing cholangitis: start annual surveillance at PSC diagnosis. (academic.oup.com)
Risk‑stratified intervals
Risk level | Typical interval | Examples of risk factors |
|---|---|---|
High | Every year | PSC, recent stricture or dysplasia, extensive colitis with severe active inflammation, strong family history under age 50 |
Intermediate | Every 2–3 years | Extensive colitis with mild to moderate inflammation, post‑inflammatory polyps, family history at or over age 50 |
Low | Every 5 years | Limited colitis, quiescent disease, no additional risk factors |
These schedules assume high‑quality prior exams and good bowel prep. The interval may shorten after incomplete exams or poor prep. (academic.oup.com)
How to do surveillance well
Use high‑definition scopes, careful washing, and unhurried inspection. Dye‑spray chromoendoscopy or high‑quality virtual chromoendoscopy improves detection. Targeted biopsies are preferred, with random biopsies in selected higher‑risk settings. Surveillance works best when inflammation is quiet. (gastro.org)
Managing dysplasia findings
Visible lesions should be removed endoscopically when en bloc and with clear margins, followed by close interval surveillance.
If pathology shows invisible low‑grade dysplasia, repeat an expert chromoendoscopy in 3–6 months to unmask a lesion. High‑grade or multifocal dysplasia generally triggers a colectomy discussion. (pmc.ncbi.nlm.nih.gov)
A simple example plan
Early phase after a new therapy: symptom check‑ins, fecal calprotectin at about 8–12 weeks, then adjust care based on results. Endoscopy if biomarkers stay high or symptoms persist. (pubmed.ncbi.nlm.nih.gov)
Stable remission: fecal calprotectin or lactoferrin and CRP every 6–12 months, medication safety labs per drug class, and on‑time cancer surveillance according to risk. Routine endoscopy is not needed when biomarkers are normal and symptoms are absent. (gastro.org)
FAQs
What number counts as “normal” fecal calprotectin in UC remission
Many teams use under 150 µg/g to help rule out active inflammation and defer routine endoscopy when symptoms are controlled. Trends matter. A steady rise deserves attention even if values are near the threshold. (gastro.org)
If symptoms are quiet but biomarkers rise, what happens next
Guidelines suggest endoscopic assessment rather than automatic medication changes. This checks for smoldering inflammation, infection, or another cause. (gastro.org)
Why is chromoendoscopy often recommended during surveillance
Color contrast, either with dye or virtual settings, helps reveal flat or subtle lesions that standard white light can miss, especially in scarred mucosa. (gastro.org)
Does achieving MES 0 really matter
Yes. People with MES 0 have fewer relapses than those with MES 1, which is why many care teams aim for 0 when possible. (bmcgastroenterol.biomedcentral.com)