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gi.peptic-ulcer.core.v1

Peptic Ulcer Disease

gastroenterologyacutechronicadultoutpatientacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is full and current (ACG 2024 HP + Maastricht VI/Florence 2022 + ACG 2021 UGIB + AGA 2024 PPI + COMPASS + COGENT + SUP-ICU) with 10 phenotypes (HP-gastric, HP-duodenal, NSAID, stress-ulcer, ZES, bleeding-Forrest, perforated, refractory, on-anticoag, marginal post-bariatric) and full medication/dosing tables for HP eradication regimens. Problem-package at peptic-ulcer-disease/ has all atoms; no `_design-brief.md`. Workup `dyspepsia` (Rome IV + ACG 2017) is the entry point. GBS, AIMS-65, HAS-BLED calculators wired. Gaps for INTEGRATED: no design brief md file; evidence.pmids array empty (manifest cites guideline labels but no numeric PMIDs); no engine-specific test_files; vonoprazan RxCUI in manifest is flagged as `2604577 (TBD — verify RxNorm CUI)`. No regimen_axes — PPIs (omeprazole, esomeprazole, pantoprazole, lansoprazole, rabeprazole), vonoprazan P-CAB, HP antibiotics (amoxicillin, clarithromycin, metronidazole, tetracycline, bismuth, rifabutin, levofloxacin), sucralfate, misoprostol all in manifest.medications without RxCUI verification through regimen-builder.

Entry points (5)

  • symptom
    Epigastric pain — relieved or worsened by meals (ACG 2024)
    epigastric_pain
  • symptom
    Chronic dyspepsia ± alarm features (ACG 2024)
    dyspepsia
  • symptom
    Hematemesis / melena → bleeding PUD (ACG 2024)
    hematemesis_melena
  • symptom
    Acute abdomen + pneumoperitoneum → perforation (ACG 2024)
    acute_abdomen_perforation
  • lab_abnormality
    Iron deficiency anemia / occult blood (ACG 2024)
    iron_deficiency_anemia

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Alarm features age >55; ZES/MEN1 screen; surgical risk (ACG 2024)
  • sbprequired
    vital • used at CONTEXT
    Hypotension in bleeding/perforation (ACG 2024)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia / shock index for bleeding PUD (ACG 2024)
  • hemoglobinrequired
    lab • used at INITIAL_WORKUP
    Bleeding severity; transfusion threshold (ACG 2024)
  • plateletsrequired
    lab • used at INITIAL_WORKUP
    Coagulopathy management (ACG 2024)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Renal dosing antibiotics; CKD-EPI (ACG 2024)
  • h_pylori_testrequired
    lab • used at INITIAL_WORKUP
    Eradication mandatory for HP-positive PUD; UBT or stool antigen with washout (ACG 2024)
  • fasting_gastrin
    lab • used at BRANCHING_WORKUP
    ZES screen if refractory or atypical (off PPI 7d, on H2RA temporarily) (ACG 2024)
  • egd_with_biopsyrequired
    imaging • used at INITIAL_WORKUP
    Diagnosis + biopsy + Forrest classification + HP testing (ACG 2024)
  • ct_abdomen_perforation
    imaging • used at BRANCHING_WORKUP
    Free air on upright CXR / CT for perforation (ACG 2024)
  • nsaid_aspirin_userequired
    history • used at CONTEXT
    NSAID PUD pathway; COX-2 + PPI co-therapy (ACG 2024)
  • anticoag_antiplateletrequired
    history • used at CONTEXT
    Hold/reverse decisions; PPI co-prescription mandatory (COMPASS, COGENT) (ACG 2024)
  • prior_hp_treatmentrequired
    history • used at CONTEXT
    Salvage regimen selection (rifabutin / levofloxacin if susceptibility known) (ACG 2024)
  • smoking_alcoholrequired
    history • used at CONTEXT
    Risk factor; cessation reduces recurrence (ACG 2024)
  • prior_bariatric_surgery
    history • used at CONTEXT
    Marginal ulcer pathway post-RYGB (ACG 2024)
  • icu_admission
    history • used at CONTEXT
    Stress ulcer prophylaxis pathway (mech vent >48h, coagulopathy, TBI, burns) (ACG 2024)

12-phase flow (12)

  1. 1FRAME
    Confirm PUD scope — acute (bleeding/perforation), chronic dyspepsia evaluation, or stress prophylaxis (ACG 2024)
    inputs: age
    advance: PUD pattern recognized
  2. 2ENTRY
    Recognize epigastric pain, dyspepsia ± alarm features, hematemesis/melena, perforation, IDA (ACG 2024)
    advance: one entry trigger present
  3. 3CONTEXT
    Vitals, NSAID/aspirin/anticoag/antiplatelet review, prior HP testing/Rx, smoking/alcohol, prior bariatric, ICU/critical illness for SUP (ACG 2024)
    inputs: sbp, hr, nsaid_aspirin_use, anticoag_antiplatelet, prior_hp_treatment, smoking_alcohol, prior_bariatric_surgery, icu_admission
    advance: context captured
  4. 4RED_FLAGS
    Hematemesis/coffee-ground, melena/hematochezia, syncope/hemodynamic instability, acute abdomen/peritonitis, unintentional weight loss, dysphagia, age >55 with new dyspepsia, persistent vomiting, IDA (ACG 2024)
    inputs: sbp, hr, hemoglobin
    advance: red flag escalated to bleeding/perforation/UGIB pathway or excluded
  5. 5INITIAL_WORKUP
    CBC, BMP, EGD with biopsy + RUT + histology, HP testing (UBT or stool antigen with PPI washout 2 wks), iron studies if anemia (ACG 2024)
    inputs: hemoglobin, platelets, creatinine, h_pylori_test, egd_with_biopsy
    actions: panel.cbc, panel.renal, dyspepsia
    advance: EGD + HP testing complete
  6. 6BRANCHING_WORKUP
    Forrest classification for bleeding; CT for perforation; fasting gastrin if refractory/atypical → ZES; secretin test; MRCP if biliary mimic (ACG 2024)
    inputs: ct_abdomen_perforation, fasting_gastrin
    advance: phenotype identified (HP-gastric, HP-duodenal, NSAID, stress-ulcer, ZES, bleeding, perforated, refractory, on-anticoag, marginal)
  7. 7DIFFERENTIAL
    Distinguish PUD from functional dyspepsia, GERD/esophagitis, gastric cancer, MALT lymphoma, gastritis, pancreatitis, biliary, Crohn upper GI, ZES, ACS inferior MI (ACG 2024)
    advance: diagnosis confirmed (location + etiology + complication)
  8. 8RISK_STRATIFICATION
    Glasgow-Blatchford for bleeding triage (≤1 → outpatient eligible); HAS-BLED on anticoagulation; Forrest classification post-EGD (ACG 2024)
    inputs: hemoglobin, sbp
    actions: calc.glasgow_blatchford, calc.has_bled, calc.aims65
    advance: severity score documented
  9. 9TREATMENT
    PPI healing course; HP eradication (bismuth quad 14d, concomitant quad 14d, vonoprazan dual 14d, rifabutin/levofloxacin salvage); endoscopic hemostasis Forrest Ia/Ib/IIa + post-EGD IV PPI 72h; surgical Graham patch for perforation; SUP in ICU; PPI co-prescription on DAPT/OAC (ACG 2024)
    inputs: creatinine
    advance: eradication regimen + PPI + lifestyle plan in motion
  10. 10DISPOSITION
    OR for perforation; ICU/floor for bleeding; outpatient for uncomplicated (ACG 2024)
    inputs: sbp
    advance: destination set
  11. 11MONITORING
    HP eradication test ≥4w post-Rx; repeat EGD 8-12w for gastric ulcer (mandatory; biopsy malignancy), serial CBC for bleeding, gastrin q6-12mo if ZES, PPI long-term safety reassessment annually (ACG 2024)
    inputs: hemoglobin
    advance: eradication confirmed and healing documented
  12. 12FOLLOWUP
    4w symptom check + HP eradication test, 8-12w repeat EGD for gastric ulcer, 2w post-bleed clinic, post-op for perforation, ZES long-term surveillance, PPI step-down assessment (ACG 2024)
    advance: follow-up scheduled