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gi.ulcerative-colitis.core.v1

Ulcerative Colitis

gastroenterologychronicacuteadultoutpatientinpatienttransition
Start encounter →Print handoutPRODUCTION

Manifest is full and current (ACG 2025 + AGA 2024 living guideline + ECCO 2022/2024 + NICE NG130 + LUCENT + TRUE NORTH + ELEVATE + U-ACHIEVE + UNIFI + OCTAVE + ACT + VARSITY) with 10 phenotypes (E1/E2/E3 + mild/moderate/severe/ASUC + pregnancy + PSC + steroid-dependent-refractory) and full medication/dosing tables for all advanced therapies (anti-TNF, vedolizumab, ustekinumab, JAKi, S1P, IL-23i). Problem-package at ulcerative-colitis/ has all atoms; no `_design-brief.md`. Workup `toxic_megacolon` is registered in clinical-tools-registry. Mayo score and Truelove-Witts calculators are referenced as calc_mayo_score / calc_truelove_witts but NOT yet in BUILTIN_CALCULATORS — engine flagged this gap explicitly. 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; calc_mayo_score + calc_truelove_witts must be added to BUILTIN_CALCULATORS before promoting; calc_uceis pending. No regimen_axes — full induction (mesalamine oral/rectal, sulfasalazine, prednisone, budesonide MMX, hydrocortisone IV) + advanced therapies (infliximab, adalimumab, vedolizumab, ustekinumab, tofacitinib, upadacitinib, ozanimod, etrasimod, mirikizumab, cyclosporine rescue) + maintenance (azathioprine, 6-MP) all in manifest.medications without RxCUI verification through regimen-builder.

Entry points (6)

  • symptom
    Bloody diarrhea ± urgency / tenesmus
    bloody_diarrhea
  • symptom
    Chronic rectal bleeding / mucous in stool
    rectal_bleeding_chronic
  • symptom
    Severe flare with systemic toxicity (Truelove-Witts)
    severe_flare_systemic_toxicity
  • lab_abnormality
    Elevated fecal calprotectin / CRP
    elevated_calprotectin
  • imaging
    Colonoscopy showing continuous colitis from rectum
    colitis_on_colonoscopy
  • problem_list
    Existing UC on problem list (flare or maintenance visit)
    ulcerative_colitis

Required inputs (20)

  • agerequired
    demographic • used at CONTEXT
    JAKi contraindications in elderly; pediatric considerations
  • temperaturerequired
    vital • used at CONTEXT
    Truelove-Witts: temp >37.8 → severe
  • hrrequired
    vital • used at CONTEXT
    Truelove-Witts: HR >90 → severe; toxic megacolon screen
  • sbprequired
    vital • used at CONTEXT
    Hemodynamic stability; ASUC severity
  • hemoglobinrequired
    lab • used at INITIAL_WORKUP
    Truelove-Witts: Hgb <10.5 → severe; transfusion threshold
  • crprequired
    lab • used at INITIAL_WORKUP
    Disease activity; Truelove-Witts and Travis Day 3 Oxford criteria
  • fecal_calprotectinrequired
    lab • used at INITIAL_WORKUP
    Mucosal inflammation surrogate (excellent for colonic disease)
  • esrrequired
    lab • used at INITIAL_WORKUP
    Truelove-Witts: ESR >30 → severe
  • albuminrequired
    lab • used at INITIAL_WORKUP
    Severity / nutritional status
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Drug dosing; pre-biologic
  • cdiff_toxinrequired
    lab • used at INITIAL_WORKUP
    C. diff superinfection mandatory exclusion in flares
  • cmv_pcr_biopsy
    lab • used at BRANCHING_WORKUP
    CMV superinfection exclusion in steroid-refractory ASUC
  • tpmt_nudt15
    lab • used at TREATMENT
    Thiopurine dosing safety
  • tb_quantiferon
    lab • used at TREATMENT
    Pre-biologic latent TB
  • hepatitis_b_screen
    lab • used at TREATMENT
    Pre-biologic HBV reactivation risk
  • colonoscopy_with_biopsiesrequired
    imaging • used at INITIAL_WORKUP
    Diagnostic + Mayo endoscopic subscore + UCEIS
  • abdominal_xray_toxic_megacolon
    imaging • used at BRANCHING_WORKUP
    AXR daily in ASUC — transverse colon >5.5cm = toxic megacolon
  • prior_uc_therapy_responserequired
    history • used at CONTEXT
    Maintenance choice depends on prior 5-ASA/biologic/JAKi/S1P response/failure
  • pregnancy_status
    history • used at CONTEXT
    Methotrexate / JAKi / S1P contraindicated; biologic continuation pathway
  • psc
    history • used at CONTEXT
    PSC-UC — annual chromoendoscopy from PSC dx; high CRC risk

12-phase flow (12)

  1. 1FRAME
    Confirm UC scope; distinguish from Crohn colitis, infectious colitis, IBS
    inputs: age
    advance: IBD pattern recognised, UC type confirmed
  2. 2ENTRY
    Recognize bloody diarrhea, urgency, tenesmus, severe flare, or known-UC visit
    advance: one entry trigger present
  3. 3CONTEXT
    Vitals, prior UC therapy + responses, steroid exposure, biologic history, EIMs, smoking, NSAID/abx exposure, pregnancy, PSC, family hx
    inputs: temperature, hr, sbp, prior_uc_therapy_response, pregnancy_status, psc
    advance: context captured
  4. 4RED_FLAGS
    Toxic megacolon, colonic perforation, massive hemorrhage, ASUC (Truelove-Witts), hemodynamic instability, peritonitis, severe electrolyte derangement, VTE/PE on immunosuppression, CMV refractory, new colonic stricture (CRC concern)
    inputs: sbp, hemoglobin, temperature, hr, esr
    advance: red flag escalated to inpatient pathway or excluded
  5. 5INITIAL_WORKUP
    CBC, CRP/ESR, fecal calprotectin, CMP/albumin, stool C. diff + culture + ova/parasites, colonoscopy with biopsies, LFTs (PSC screen), iron studies, vit D
    inputs: hemoglobin, crp, esr, albumin, creatinine, fecal_calprotectin, cdiff_toxin, colonoscopy_with_biopsies
    actions: panel.cbc, panel.lft, panel.renal
    advance: baseline workup + colonoscopy returned
  6. 6BRANCHING_WORKUP
    AXR for toxic megacolon in severe; CMV biopsy/PCR if steroid-refractory; pre-biologic TPMT/NUDT15, TB, HBV; CT for complications
    inputs: cmv_pcr_biopsy, abdominal_xray_toxic_megacolon, tpmt_nudt15, tb_quantiferon, hepatitis_b_screen
    actions: toxic_megacolon
    advance: phenotype identified (E1 proctitis / E2 left-sided / E3 extensive / mild / moderate / severe / ASUC / pregnancy / PSC / steroid-dependent-refractory)
  7. 7DIFFERENTIAL
    Distinguish UC from Crohn colitis, infectious colitis (C. diff), CMV colitis, ischemic, microscopic, NSAID-induced, radiation, diverticular, CRC, IBS, celiac, Behçet
    advance: diagnosis confirmed (Montreal extent + severity)
  8. 8RISK_STRATIFICATION
    Montreal extent E1/E2/E3; full Mayo score + ACG UCDAI 2025; Truelove-Witts severity; endoscopic Mayo + UCEIS; Travis Day-3 Oxford for ASUC steroid response prediction
    inputs: hemoglobin, esr, crp
    advance: severity + extent assigned
  9. 9TREATMENT
    Mild: oral + topical 5-ASA. Moderate: oral steroids/budesonide MMX + advanced therapy (anti-TNF, vedolizumab, ustekinumab, JAKi tofacitinib/upadacitinib, S1P ozanimod/etrasimod, IL-23 risankizumab/mirikizumab/guselkumab). Severe/ASUC: IV steroids + Day-3 assessment + rescue infliximab/cyclosporine + colectomy if refractory. VTE prophylaxis + iron repletion + CRC surveillance
    inputs: creatinine, tpmt_nudt15, tb_quantiferon, hepatitis_b_screen
    advance: induction + maintenance plan agreed
  10. 10DISPOSITION
    ICU/inpatient for ASUC / toxic megacolon / massive bleed; floor for severe flare; outpatient for mild-moderate
    inputs: sbp
    advance: destination set
  11. 11MONITORING
    Calprotectin + CRP q3-6mo, CBC/LFT q3mo on immunomodulator, thiopurine metabolites, biologic trough + ADA, lipid panel on JAKi, ECG pre-S1P, CRC surveillance colonoscopy q1-3yr per duration/extent, bone density on chronic steroids
    inputs: crp, fecal_calprotectin, hemoglobin
    advance: monitoring cadence set
  12. 12FOLLOWUP
    Post-induction 8-12w; maintenance q3-6mo stable; flare urgent <1w; ASUC daily inpatient; post-colectomy surgical follow-up; CRC surveillance; preconception counselling
    advance: follow-up scheduled