Harvey-Bradshaw Index (Crohn's)

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What is the difference between Harvey-Bradshaw Index and CDAI?

The CDAI (Crohn's Disease Activity Index) is the traditional research gold standard, requiring a 7-day diary of stool frequency, abdominal pain, general well-being, use of anti-diarrhoeal drugs, presence of abdominal mass, haematocrit, and body weight. A CDAI <150 = remission; >450 = severe. The HBI is simpler, requires no diary, and can be completed in minutes at a single consultation. HBI correlates strongly with CDAI (r = 0.93) and is the preferred routine clinical tool in Europe. CDAI is still required for some clinical trial regulatory endpoints.

How is the number of liquid stools scored in the HBI?

The patient is asked how many liquid or very soft stools they had in the previous day (not the past week). This number is added directly to the score. For example, 5 liquid stools contributes 5 points. This is different from the Mayo Score for UC, which uses a relative comparison to the patient's baseline. The HBI liquid stool count is an absolute value for the previous 24 hours.

What endoscopic scoring systems complement the HBI?

The Simple Endoscopic Score for Crohn's Disease (SES-CD) and the Crohn's Disease Endoscopic Index of Severity (CDEIS) are used to quantify endoscopic disease activity at colonoscopy. SES-CD is simpler and more widely used: it scores ulcer size, ulcerated surface, affected surface, and narrowings in each colonic segment. Endoscopic remission (mucosal healing) is defined as SES-CD <3 or CDEIS <4. Endoscopic assessment is essential before starting or switching biologic therapy.

What is the treat-to-target strategy in Crohn's disease?

Treat-to-target (T2T) in Crohn's disease involves selecting measurable treatment targets — typically clinical remission (HBI <5 or CDAI <150) AND mucosal healing (SES-CD <3 or absence of deep ulceration) — and monitoring patients regularly with clinical scores, biomarkers (CRP, calprotectin), and endoscopy/cross-sectional imaging. The CALM trial demonstrated that calprotectin-guided step-up therapy (targeting mucosal healing, not just clinical remission) improved endoscopic outcomes compared to symptom-guided management alone.

What biologics are approved for Crohn's disease?

Biologics for Crohn's disease include: anti-TNF agents (infliximab, adalimumab — first approved, most evidence for perianal disease; certolizumab pegol in some countries), anti-integrin (vedolizumab — gut-selective, fewer systemic side effects), anti-IL-12/23 (ustekinumab — effective for luminal and perianal Crohn's), and anti-IL-23p19 (risankizumab — newest, approved 2023). Small molecules include upadacitinib (JAK1 inhibitor, approved for moderate-to-severe CD 2023). Selection depends on prior treatment history, extraintestinal manifestations, and comorbidities.

What is the role of immunomodulators (azathioprine, methotrexate) in Crohn's?

Immunomodulators (azathioprine/6-mercaptopurine, methotrexate) are used to maintain remission in steroid-dependent Crohn's and to prevent immunogenicity when co-prescribed with anti-TNF biologics (combination therapy reduces formation of anti-drug antibodies). They are not effective for acute flares. Thiopurine methyltransferase (TPMT) and NUDT15 genotyping should be performed before starting azathioprine to identify patients at risk of severe myelosuppression. Methotrexate is an alternative for patients intolerant to or who fail thiopurines.

When is surgery considered in Crohn's disease?

Surgery is indicated for: bowel perforation, obstruction from stricture, abscess not amenable to drainage, refractory fistula, severe bleeding, cancer, or disease refractory to all medical therapies. Unlike UC (where colectomy is curative), surgery for Crohn's is not curative — disease commonly recurs at the anastomosis. Ileocaecal resection is the most common procedure. Post-operative infliximab (or adalimumab) prophylaxis reduces endoscopic and clinical recurrence rates significantly.

What is the relationship between smoking and Crohn's disease?

Smoking has opposite effects in IBD: it worsens Crohn's disease (increases flares, stricture formation, and need for surgery; impairs response to infliximab) and paradoxically appears to protect against ulcerative colitis. All patients with Crohn's disease who smoke must be strongly advised to stop — smoking cessation is one of the most effective disease-modifying interventions available. Ex-smokers with Crohn's disease have outcomes similar to lifelong non-smokers.