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gi.crohns.core.v1PRODUCTION
gi.crohns.core.v1

Crohn's Disease

gastroenterologychronicacuteadult
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0 / 14
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm CD scope (chronic IBD with potential acute flare); distinguish from UC, infectious colitis, IBS, TB

Inputs
1
Actions
0
Advance rule
Set
Advance when

IBD pattern recognized

Patient inputs (20)

Paediatric onset triggers EEN + transition pathway; elderly drives biologic safety profile

Fever in flare / abscess / sepsis

Tachycardia in severe flare / sepsis

Hypotension in obstruction / sepsis / GI bleed

Smoking worsens CD course; cessation is high-yield intervention

Steroid exposure, biologic history, response/failure pattern

Inflammatory marker; tracks disease activity

Mucosal inflammation surrogate (best for colonic CD)

Anemia (chronic disease + iron deficiency); leukocytosis in flare

Nutritional status + protein-losing enteropathy

Drug dosing; pre-biologic baseline

Iron deficiency anemia common

Diagnostic + endoscopic activity (SES-CD)

Small-bowel + transmural assessment; stricturing vs penetrating

Gold standard for perianal fistula mapping

Methotrexate/JAKi/S1P contraindicated; biologic continuation pathway

Joint/skin/eye/PSC EIMs guide therapy choice

Thiopurine dosing safety

Pre-biologic latent TB screen

Pre-biologic HBV screen (reactivation risk)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationalseveresevere flare with systemic toxicity (ACG 2018)
    CDAI ≥450 OR Harvey-Bradshaw ≥9 OR fever + tachycardia + rapid weight loss (ACG 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereintra-abdominal abscess (ACG 2018)
    CT shows abscess >3-5 cm in CD (ACG 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacute intestinal obstruction (ACG 2018)
    Bilious/feculent vomiting + obstipation + dilated bowel on imaging (ACG 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereperianal disease abscess or fistula (ACG 2018)
    Perianal pain, fluctuance, or new fistula tract (ACG 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresteroid refractory severe flare (ACG 2018)
    No improvement after 3-5 days of IV methylprednisolone (ACG 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepregnancy with active CD (Mahadevan Gastro 2019)
    Active CD or planning pregnancy (ECCO 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpre-biologic TB/HBV screen required (ACG 2018)
    Planning anti-TNF, anti-IL-12/23, or anti-IL-23 initiation (ACG 2018; ECCO 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

Crohn's disease severity-driven induction + maintenance — ACG 2018+2024 + AGA 2021 + ECCO 2023/2024
axis: crohns_severity_pathwaystep 1 - Step 1 — Mild luminal CD (low-risk phenotype)
Selected step "Step 1 — Mild luminal CD (low-risk phenotype)" — Mild symptoms, no high-risk features (deep ulcers, perianal, young, extensive disease), CDAI <220
  • budesonide
    first line
    corticosteroid_oral_low_systemic
    9 mg PO daily × 8-12 weeks • PO • daily
    triggers: mild_ileal_or_right_colonic_CD
    AGA 2021 — first-line induction for mild ileocolonic CD; lower systemic effects than prednisone
    rxcui 19831

outpatient playbook — drug actions (7)

  1. 1. budesonide for mild ileocolonic
    9 mg PO daily × 8-12 weeks • PO • daily
    trigger: Mild low-risk CD
    AGA 2021
  2. 2. anti-TNF (infliximab/adalimumab)
    IFX 5 mg/kg IV at 0,2,6w then q8w; ADA 160→80 mg→40 mg q2w • IV/SC • per agent
    trigger: Moderate-severe / high-risk
    ACCENT/CHARM
  3. 3. risankizumab IL-23i
    600 mg IV at 0,4,8w then 360 mg SC q8w • IV → SC • q8w
    trigger: Moderate-severe; SEQUENCE-aligned
    ADVANCE/MOTIVATE/FORTIFY/SEQUENCE
  4. 4. ustekinumab
    Weight-based IV → 90 mg SC q8w • IV → SC • q8w
    trigger: Safety preference, anti-TNF failure
    UNITI
  5. 5. upadacitinib JAKi
    45 mg PO daily × 12w → 30 or 15 mg daily • PO • daily
    trigger: Oral preference, anti-TNF failure
    SELECT-CD/U-EXCEL
  6. 6. azathioprine maintenance
    2-2.5 mg/kg PO daily (TPMT-adjusted) • PO • daily
    trigger: Combination with anti-TNF in biologic-naive
    SONIC
  7. 7. IV iron
    Ferric carboxymaltose 750 mg IV × 1-2 • IV • per regimen
    trigger: Iron deficiency anemia
    PO often poorly tolerated in active CD

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Chronic diarrhea ± rectal bleeding; RLQ abdominal pain + weight loss; Perianal pain / fistula / abscess.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Crohn's Disease** (gi.crohns.core.v1).
Phenotype framing: Distinguish CD from UC, IBS, infectious colitis, intestinal TB, celiac, NSAID enteropathy, GI lymphoma, colorectal cancer, Behçet, ischemic / microscopic colitis
Scope: Confirm CD scope (chronic IBD with potential acute flare); distinguish from UC, infectious colitis, IBS, TB

No severity triggers fired against current inputs.

Plan

Regimen axis: **Crohn's disease severity-driven induction + maintenance — ACG 2018+2024 + AGA 2021 + ECCO 2023/2024** — step "Step 1 — Mild luminal CD (low-risk phenotype)".
1. budesonide 9 mg PO daily × 8-12 weeks PO daily (corticosteroid_oral_low_systemic, first line) — AGA 2021 — first-line induction for mild ileocolonic CD; lower systemic effects than prednisone

Setting playbook (outpatient) — Confirm diagnosis (Montreal classification), risk-stratify (low vs high-risk phenotype), induction and maintenance per ACG/AGA/ECCO, complications surveillance, vaccinations, preconception planning
2. budesonide for mild ileocolonic 9 mg PO daily × 8-12 weeks PO daily — Mild low-risk CD (AGA 2021)
3. anti-TNF (infliximab/adalimumab) IFX 5 mg/kg IV at 0,2,6w then q8w; ADA 160→80 mg→40 mg q2w IV/SC per agent — Moderate-severe / high-risk (ACCENT/CHARM)
4. risankizumab IL-23i 600 mg IV at 0,4,8w then 360 mg SC q8w IV → SC q8w — Moderate-severe; SEQUENCE-aligned (ADVANCE/MOTIVATE/FORTIFY/SEQUENCE)
5. ustekinumab Weight-based IV → 90 mg SC q8w IV → SC q8w — Safety preference, anti-TNF failure (UNITI)
6. upadacitinib JAKi 45 mg PO daily × 12w → 30 or 15 mg daily PO daily — Oral preference, anti-TNF failure (SELECT-CD/U-EXCEL)
7. azathioprine maintenance 2-2.5 mg/kg PO daily (TPMT-adjusted) PO daily — Combination with anti-TNF in biologic-naive (SONIC)
8. IV iron Ferric carboxymaltose 750 mg IV × 1-2 IV per regimen — Iron deficiency anemia (PO often poorly tolerated in active CD)

Non-pharmacologic actions:
- Smoking cessation (highest-yield modifiable)
- EEN consideration in pediatric CD
- Perianal MRI if fistulizing → drainage + seton + IFX
- Preconception counselling + biologic continuation through pregnancy
- Vaccinations (flu, pneumococcal, HBV if non-immune, COVID, RSV per age, no live vaccines on biologic)
- CRC surveillance per extent and duration (q1-3y for extensive)
- DEXA if steroid exposed
- Nutrition + sarcopenia evaluation

AVOID / contraindication checks:
- 5 ASA ineffective in CD; use only if mild colonic (ACG 2018)
- Methotrexate contraindicated in pregnancy (ACG 2018)
- JAKi caution age >50 with CV RF per FDA (AGA 2021)
- Thiopurine check TPMT/NUDT15 pre Rx (ACG 2018; ECCO 2020)
- Anti TNF check TB/HBV pre Rx (ACG 2018; ECCO 2020)
- Vedolizumab caution active severe infection/PML (ECCO 2020)
- Vaccinate pre biologic; avoid live vaccines during immunosuppression (ACG 2018; NICE 2019)
- Pregnancy continue biologics through pregnancy with PIANO data (Mahadevan Gastro 2019)

Monitoring

Regimen monitoring:
- fecal calprotectin q3-6mo (STRIDE-II Turner 2021)
- CRP q3-6mo (STRIDE-II Turner 2021)
- CBC/LFT/BMP on immunomodulator (ACG 2018)
- biologic trough and ADA at week 14 (AGA 2021)
- endoscopic reassessment 6-12mo for remission (STRIDE-II Turner 2021)
- CRC surveillance per extent and duration (ACG 2018; ECCO 2020)
- DEXA if steroid exposed (ACG 2018)
- annual TB/HBV check (ECCO 2020)
- lipid panel q3mo on JAKi (AGA 2021)
- PML surveillance on vedolizumab (ECCO 2020)

Setting (outpatient) monitoring:
- Calprotectin + CRP q3-6 mo (STRIDE-II Turner 2021)
- CBC/LFT/BMP q3 mo on immunomodulator (ACG 2018)
- Biologic trough + ADA at week 14 (AGA 2021)
- Endoscopic reassessment 6-12 mo (STRIDE-II Turner 2021)
- Annual TB/HBV check (ECCO 2020)
- CRC colonoscopy (ACG 2018)
- Lipid panel q3mo on JAKi (AGA 2021)

Follow-up plan: q2-4w during induction, q3mo first year maintenance, q6mo stable remission; postop colonoscopy 6-12mo (Rutgeerts); annual comprehensive review; preconception counselling
- Close-out criterion: follow-up scheduled

Monitoring phase: Calprotectin + CRP q3-6mo, CBC/LFT/BMP on immunomodulator, biologic trough levels + ADA, endoscopic reassessment 6-12mo, CRC surveillance, DEXA if steroid exposed

Disposition

Current setting: outpatient — Confirm diagnosis (Montreal classification), risk-stratify (low vs high-risk phenotype), induction and maintenance per ACG/AGA/ECCO, complications surveillance, vaccinations, preconception planning

Disposition criteria:
- Continue maintenance if remission (STRIDE-II Turner 2021)
- Step up if active despite induction (ACG 2018)
- Switch class if loss of response with adequate trough + ADA (AGA 2021)

Escalation triggers (move to higher acuity):
- Acute obstruction → ED / inpatient (ACG 2018)
- Abscess / perforation → ED / surgery (ACG 2018; ECCO 2020)
- Severe flare → inpatient (ACG 2018)
- Failed biologic → switch class with TDM (AGA 2021)

Patient Action Plan

**Crohn's disease flare action plan**
Personalised values: baseline_calprotectin_CRP, maintenance_therapy, prior_steroid_response, high_risk_features.

**In remission — continue maintenance** (green):
Triggers:
- Stable bowel pattern (≤3 BMs/day, formed or soft, no blood)
- No abdominal pain
- Normal energy and appetite
- Calprotectin <250 (if measured)
Actions:
- Take maintenance therapy as prescribed (do not skip biologic)
- No NSAIDs
- Smoking cessation
- Keep IBD clinic appointments
- Annual labs and surveillance per IBD plan

**Caution — early flare, contact IBD team within 24-48 hours** (yellow):
Triggers:
- Increased BM frequency (>4-5/day) for >3 days
- New or worsening abdominal pain
- Visible blood in stool
- Low-grade fever (37.5-38.5°C)
- Weight loss or anorexia
- New joint pain or skin lesions
Actions:
- Continue maintenance therapy
- Hydrate and rest
- Contact IBD team within 24-48 hours
- Stool sample for C. diff if available
- Clinic visit may include calprotectin, CRP, possible budesonide or steroid course
Contact provider when:
- Symptoms worsening despite home measures
- Fevers >38.5°C
- Weight loss >5%
- Severe joint/skin/eye involvement

**Medical alert — go to ED now** (red):
Triggers:
- Severe abdominal pain or rigid abdomen (perforation)
- Vomiting + obstipation (obstruction)
- Massive bleeding from rectum
- High fever >39°C with shaking chills
- Severe dehydration / lightheaded
- Perianal abscess with fever
Actions:
- Call 911 / go to nearest ED immediately
- Bring updated medication list
- Notify IBD team of admission
Contact provider when:
- Any red zone symptom — ED now, do not wait

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] CDAI ≥450 OR Harvey-Bradshaw ≥9 OR fever + tachycardia + rapid weight loss (ACG 2018)
- [SEVERE] CT shows abscess >3-5 cm in CD (ACG 2018)
- [SEVERE] Bilious/feculent vomiting + obstipation + dilated bowel on imaging (ACG 2018)

Citations

- ACG 2018 Crohn + ACG 2024 update + AGA 2021 Moderate-Severe CD + ECCO 2023/2024 + BSG 2024 IBD + SONIC (NEJM 2010) + ADVANCE/MOTIVATE/FORTIFY (Lancet 2022) + SELECT-CD (NEJM 2023) + SEQUENCE (Lancet 2024) + GALAXI 1/2/3 (Lancet 2024) [PMID:20393175](https://pubmed.ncbi.nlm.nih.gov/20393175/)
- Cited evidence (PMID 29096949) [PMID:29096949](https://pubmed.ncbi.nlm.nih.gov/29096949/)
- Cited evidence (PMID 26342731) [PMID:26342731](https://pubmed.ncbi.nlm.nih.gov/26342731/)
- Cited evidence (PMID 35644154) [PMID:35644154](https://pubmed.ncbi.nlm.nih.gov/35644154/)
- Cited evidence (PMID 35644155) [PMID:35644155](https://pubmed.ncbi.nlm.nih.gov/35644155/)

Last reconciled with current guidelines: 2026-05-22.
References
  • ACG 2018 Crohn + ACG 2024 update + AGA 2021 Moderate-Severe CD + ECCO 2023/2024 + BSG 2024 IBD + SONIC (NEJM 2010) + ADVANCE/MOTIVATE/FORTIFY (Lancet 2022) + SELECT-CD (NEJM 2023) + SEQUENCE (Lancet 2024) + GALAXI 1/2/3 (Lancet 2024) — PMID:20393175
  • Cited evidence (PMID 29096949) — PMID:29096949
  • Cited evidence (PMID 26342731) — PMID:26342731
  • Cited evidence (PMID 35644154) — PMID:35644154
  • Cited evidence (PMID 35644155) — PMID:35644155