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PUCAI score calculator
The Pediatric Ulcerative Colitis Activity Index (PUCAI) scores how active ulcerative colitis is in a child from six symptoms: abdominal pain, rectal bleeding, stool consistency, number of stools, night-time stools and activity. The total runs from 0 to 85. Under 10 is remission, 10 to 34 mild, 35 to 64 moderate, and 65 or more severe. A change of 20 points or more is clinically meaningful.
Clinical disclaimer
How PUCAI is scored
Add the points for each item. Score all six items from the same visit, and don't mix older symptoms with current ones.
- Abdominal pain: none 0; pain can be ignored 5; pain cannot be ignored 10.
- Rectal bleeding: none 0; small amount only, in under 50% of stools 10; small amount with most stools 20; large amount (over 50% of the stool content) 30.
- Consistency of most stools: formed 0; partially formed 5; completely unformed 10.
- Number of stools per 24 hours: 0 to 2 is 0; 3 to 5 is 5; 6 to 8 is 10; more than 8 is 15.
- Nocturnal stools (any episode causing wakening): no 0; yes 10.
- Activity level: no limitation 0; occasional limitation 5; severe restricted activity 10.
What the score means
- Under 10: remission. Ten points was the best cutoff between remission and active disease in 215 children (Turner 2009).
- 10 to 34: mild disease.
- 35 to 64: moderate disease.
- 65 to 85: severe disease. The 2018 ECCO/ESPGHAN acute severe colitis guideline scores PUCAI daily to guide care.
- Change over time: a fall of 20 points or more is a clinically meaningful response.
The ECCO/ESPGHAN 2018 guidelines build their ambulatory and acute severe colitis treatment algorithms around repeated PUCAI scores. Treatment choices follow those guidelines and your IBD team, not the score alone.
Who PUCAI is for, and its limits
- Developed and validated in children with ulcerative colitis (Turner 2007: 157 children for weighting, 48 for validation against colonoscopy, 75 for responsiveness).
- It correlated closely with physician global assessment (r = 0.91), the Mayo score (r = 0.95) and colonoscopic appearance (r = 0.77).
- It is non-invasive, which is why trials and the EMA accept it as an outcome measure in pediatric UC. EMA noted validity in very young children is less certain.
- It is not for Crohn's disease. Infection, especially C. difficile, can raise the score without a true flare.
Related tools
- PCDAI calculator for Crohn's disease activity.
- Steroid conversion calculator for approximate equivalent doses between steroids.
- Dehydration in children calculator to score dehydration during a flare.
- Weight percentile calculator to track growth.
References
- Turner D, Otley AR, Mack D, et al. Development, validation, and evaluation of a pediatric ulcerative colitis activity index: a prospective multicenter study. Gastroenterology. 2007;133(2):423-432.
- Turner D, Hyams J, Markowitz J, et al. Appraisal of the pediatric ulcerative colitis activity index (PUCAI). Inflamm Bowel Dis. 2009;15(8):1218-1223.
- European Medicines Agency. Qualification opinion: Paediatric Ulcerative Colitis Activity Index (PUCAI). EMA/CHMP/SAWP/801872/2015.
- Turner D, Ruemmele FM, Orlanski-Meyer E, et al. Management of paediatric ulcerative colitis, part 1: ambulatory care. An ECCO/ESPGHAN guideline. J Pediatr Gastroenterol Nutr. 2018;67(2):257-291.
- Turner D, Ruemmele FM, Orlanski-Meyer E, et al. Management of paediatric ulcerative colitis, part 2: acute severe colitis. An ECCO/ESPGHAN guideline. J Pediatr Gastroenterol Nutr. 2018;67(2):292-310.
FAQs
A PUCAI below 10 points is remission. The validated bands are: under 10 remission, 10 to 34 mild, 35 to 64 moderate, and 65 or more severe disease (EMA PUCAI qualification opinion).
A change of at least 20 points. The EMA qualification opinion cites 20 points as the minimal important difference.
No. All six items are needed for a valid total. Complete the history before scoring.
It is the severe band (65 to 85). The 2018 ECCO/ESPGHAN guideline treats acute severe colitis as an emergency and builds its management flowchart around daily PUCAI scores. Involve your IBD team and follow your local pathway.
No. It uses six symptom items only. Lab and endoscopic items were tested during development and did not improve it (Turner 2007). Use labs, stool calprotectin and endoscopy alongside it, not inside it.
No. PUCAI is for ulcerative colitis and IBD-unclassified. For Crohn’s disease, use the PCDAI.
Yes. An infection such as C. difficile can raise stool frequency and bleeding scores. Check for infection before reading a rising score as a UC flare.