Harvey-Bradshaw Index — Crohn's Disease Activity
General wellbeing
Bol u trbuhu
Abdominalna masa
Complications: arthralgia, uveitis, erythema nodosum, aphthous ulcers, pyoderma, anal fissure, new fistula, abscess
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The Harvey-Bradshaw Index (HBI) is a simple, validated clinical tool for assessing disease activity in Crohn's Disease (CD), developed by Harvey and Bradshaw in 1980 as a simplified alternative to the more complex Crohn's Disease Activity Index (CDAI). The HBI requires no 7-day patient diary and can be completed at any single clinical assessment, making it practical for routine outpatient monitoring. It comprises five components: (1) General Well-Being — scored 0 (very well) to 4 (terrible) reflecting the patient's subjective sense of health over the previous day; (2) Abdominal Pain — scored 0 (none) to 3 (severe) based on the predominant pain severity; (3) Number of Liquid or Very Soft Stools in the previous day — the actual number is the score; (4) Abdominal Mass — scored 0 (none), 1 (dubious), 2 (definite), 3 (definite and tender); (5) Complications — each complication present scores 1 point: arthralgia, uveitis, erythema nodosum, aphthous ulcers, pyoderma gangrenosum, anal fissure, new fistula, abscess. Disease activity is classified as: remission (HBI <5); mild disease (HBI 5–7); moderate disease (HBI 8–16); severe disease (HBI >16). The HBI correlates moderately well with the CDAI (r = 0.93) and provides similar discrimination between inactive, mild, moderate, and severe disease. In clinical trials, the primary endpoint for biologic therapy approval in Crohn's disease has traditionally used the CDAI, but the HBI is widely accepted in European clinical practice and by ECCO guidelines as an equivalent clinical disease activity measure for routine use. Biomarkers (CRP, faecal calprotectin) and endoscopic indices (SES-CD, CDEIS) complement the HBI for comprehensive disease monitoring.
HBI = General Well-Being (0–4) + Abdominal Pain (0–3) + Number of Liquid Stools (actual count) + Abdominal Mass (0–3) + Complications (1 per complication)
- 1Ask the patient about general well-being in the past day: 0 (very well), 1 (slightly below par), 2 (poor), 3 (very poor), 4 (terrible).
- 2Assess abdominal pain: 0 (none), 1 (mild), 2 (moderate), 3 (severe).
- 3Count the number of liquid or very soft stools in the previous 24 hours — this number directly contributes to the score.
- 4Palpate for abdominal mass: 0 (none), 1 (dubious/possible), 2 (definite), 3 (definite and tender on palpation).
- 5Check for and record complications: arthralgia/arthritis (joints), uveitis, erythema nodosum, aphthous ulcers, pyoderma gangrenosum, anal fissure, new fistula or abscess — each scores 1 point.
- 6Sum all components: <5 = remission; 5–7 = mild; 8–16 = moderate; >16 = severe.
- 7Correlate with CRP, faecal calprotectin, and endoscopy (SES-CD) for comprehensive assessment.
HBI <5 = clinical remission; aim for deep remission with endoscopic healing
Two liquid stools per day may be baseline for this patient; the overall score of 2 indicates clinical remission.
Confirm disease extent and activity endoscopically before committing to biologic therapy
An HBI of 10 indicates moderately active Crohn's disease. Anti-TNF biologic therapy is appropriate, particularly given the extraintestinal manifestation (arthralgia).
Infliximab is first-line biologic for perianal fistulising Crohn's disease (ACCENT II trial)
Perianal complications (fistula and abscess) each contribute 1 point to the HBI. Infliximab has specific trial evidence for fistulising Crohn's disease.
A palpable tender mass in severe Crohn's may indicate abscess, phlegmon, or perforated bowel
An HBI of 20 represents severe disease with systemic manifestations. An abdominal mass in this context requires urgent imaging to exclude surgical emergency.
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Extreme input values
In practice, this edge case requires careful consideration because standard assumptions may not hold. When encountering this scenario in harvey bradshaw cd calculations, practitioners should verify boundary conditions, check for division-by-zero risks, and consider whether the model's assumptions remain valid under these extreme conditions.
Assumption violations
In practice, this edge case requires careful consideration because standard assumptions may not hold. When encountering this scenario in harvey bradshaw cd calculations, practitioners should verify boundary conditions, check for division-by-zero risks, and consider whether the model's assumptions remain valid under these extreme conditions.
Rounding and precision effects
In practice, this edge case requires careful consideration because standard assumptions may not hold. When encountering this scenario in harvey bradshaw cd calculations, practitioners should verify boundary conditions, check for division-by-zero risks, and consider whether the model's assumptions remain valid under these extreme conditions.
| HBI Score | Disease Activity | Typical Management |
|---|---|---|
| <5 | Remission | Continue maintenance therapy; monitor calprotectin; annual or biannual review |
| 5–7 | Mild | Optimise aminosalicylates or azathioprine; budesonide for localised ileocolonic disease |
| 8–16 | Moderate | Systemic corticosteroids; step up to biologic therapy; endoscopy to confirm |
| >16 | Severe | Urgent hospital review; IV steroids; imaging; surgical consultation |
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.
Pro Tip
The number of liquid stools is the single most variable and important component of the HBI — in patients with a naturally loose stool baseline (e.g., short bowel syndrome, post-ileocaecal resection), establish their personal baseline and focus on change from baseline rather than the absolute stool count when interpreting the HBI. Document the patient's baseline stool frequency at every clinic visit to enable accurate longitudinal comparison.
Did you know?
Crohn's disease is named after Dr Burrill Bernard Crohn, a gastroenterologist at New York's Mount Sinai Hospital who, in 1932, co-authored the landmark paper 'Regional Ileitis: A Pathologic and Clinical Entity' with Leon Ginzburg and Gordon Oppenheimer. The paper described 14 cases of a previously unnamed inflammatory disease of the terminal ileum. Crohn was the first named author alphabetically, which is why the disease bears his name — Ginzburg and Oppenheimer never received equivalent recognition.
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