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gi.peptic-ulcer.core.v1PRODUCTION
gi.peptic-ulcer.core.v1

Peptic Ulcer Disease

gastroenterologyacutechronicadult
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Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm PUD scope — acute (bleeding/perforation), chronic dyspepsia evaluation, or stress prophylaxis (ACG 2024)

Inputs
1
Actions
0
Advance rule
Set
Advance when

PUD pattern recognized

Patient inputs (16)

Alarm features age >55; ZES/MEN1 screen; surgical risk (ACG 2024)

Hypotension in bleeding/perforation (ACG 2024)

Tachycardia / shock index for bleeding PUD (ACG 2024)

NSAID PUD pathway; COX-2 + PPI co-therapy (ACG 2024)

Hold/reverse decisions; PPI co-prescription mandatory (COMPASS, COGENT) (ACG 2024)

Salvage regimen selection (rifabutin / levofloxacin if susceptibility known) (ACG 2024)

Risk factor; cessation reduces recurrence (ACG 2024)

Bleeding severity; transfusion threshold (ACG 2024)

Coagulopathy management (ACG 2024)

Renal dosing antibiotics; CKD-EPI (ACG 2024)

Eradication mandatory for HP-positive PUD; UBT or stool antigen with washout (ACG 2024)

Diagnosis + biopsy + Forrest classification + HP testing (ACG 2024)

ZES screen if refractory or atypical (off PPI 7d, on H2RA temporarily) (ACG 2024)

Free air on upright CXR / CT for perforation (ACG 2024)

Marginal ulcer pathway post-RYGB (ACG 2024)

Stress ulcer prophylaxis pathway (mech vent >48h, coagulopathy, TBI, burns) (ACG 2024)

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

Severity triggers (6)

6 need judgement
  • informationallife_threateningperforation_acute_abdomen
    Free air on upright CXR / CT + peritoneal signs (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebleeding_pud_high_risk
    Forrest Ia (active spurting), Ib (oozing), IIa (visible vessel) on EGD (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehp_resistant_after_2_failed_regimens
    HP positive after 2 prior eradication attempts (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterefractory_pud_consider_zes
    Refractory PUD despite HP eradication + adequate PPI; multiple ulcers; ulcers in atypical locations (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesup_indication_icu
    Mech vent >48h OR platelets <50 OR INR >1.5 OR TBI OR severe burns (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatensaid_oac_dapt_high_risk_overlap
    Patient on NSAID, OAC, or DAPT with PUD history or active disease (ACG 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Peptic ulcer disease — PPI healing + HP eradication + complication management (ACG 2024 + Maastricht VI)
axis: pud_pathwaystep 1 - Step 1 — PPI healing course (all PUD)
Selected step "Step 1 — PPI healing course (all PUD)" — Confirmed peptic ulcer on EGD
  • omeprazole
    first line
    PPI
    20-40 mg PO daily × 4-8 weeks • PO • daily 30-60 min before meal
    triggers: duodenal_ulcer_4w, gastric_ulcer_8_to_12w
    Healing course — duodenal 4 weeks, gastric 8-12 weeks; longer for large or refractory (ACG 2024)
    rxcui 7646
  • esomeprazole
    first line
    PPI
    40 mg PO daily × 4-8 weeks • PO • daily
    Equivalent PPI option (ACG 2024)
    rxcui 283742
  • pantoprazole
    first line
    PPI
    40 mg PO/IV daily • PO/IV • daily
    IV formulation available for inpatient (ACG 2024)
    rxcui 40790
  • vonoprazan
    second line
    PCAB
    20 mg PO daily • PO • daily
    triggers: HP_resistant, PPI_failure
    P-CAB — faster, longer acid suppression than PPI; superior HP eradication in resistant cases (ACG 2024)
    rxcui 2604577

outpatient playbook — drug actions (4)

  1. 1. PPI healing course
    Omeprazole 20-40 mg PO daily × 4w (duodenal) / 8-12w (gastric) • PO • daily
    trigger: PUD diagnosed (ACG 2024)
    ACG 2024
  2. 2. HP eradication if HP+
    Bismuth quad 14d OR concomitant quad 14d OR vonoprazan-amoxicillin dual 14d • PO • per regimen
    trigger: HP positive (ACG 2024)
    ACG 2024 / Maastricht VI
  3. 3. PPI co-prescription on antiplatelet/OAC
    Omeprazole 20 mg PO daily • PO • daily
    trigger: On DAPT/OAC with prior PUD (ACG 2024)
    COMPASS/COGENT (ACG 2024)
  4. 4. NSAID withdrawal or COX-2 substitution
    Stop NSAID OR celecoxib 100-200 mg BID with PPI • PO • BID
    trigger: NSAID essential (ACG 2024)
    Reduce GI risk (ACG 2024)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Epigastric pain — relieved or worsened by meals (ACG 2024); Chronic dyspepsia ± alarm features (ACG 2024); Hematemesis / melena → bleeding PUD (ACG 2024).

Objective

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

Assessment

**Peptic Ulcer Disease** (gi.peptic-ulcer.core.v1).
Phenotype framing: Distinguish PUD from functional dyspepsia, GERD/esophagitis, gastric cancer, MALT lymphoma, gastritis, pancreatitis, biliary, Crohn upper GI, ZES, ACS inferior MI (ACG 2024)
Scope: Confirm PUD scope — acute (bleeding/perforation), chronic dyspepsia evaluation, or stress prophylaxis (ACG 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Peptic ulcer disease — PPI healing + HP eradication + complication management (ACG 2024 + Maastricht VI)** — step "Step 1 — PPI healing course (all PUD)".
1. omeprazole 20-40 mg PO daily × 4-8 weeks PO daily 30-60 min before meal (PPI, first line) — Healing course — duodenal 4 weeks, gastric 8-12 weeks; longer for large or refractory (ACG 2024)
2. esomeprazole 40 mg PO daily × 4-8 weeks PO daily (PPI, first line) — Equivalent PPI option (ACG 2024)
3. pantoprazole 40 mg PO/IV daily PO/IV daily (PPI, first line) — IV formulation available for inpatient (ACG 2024)
4. vonoprazan 20 mg PO daily PO daily (PCAB, second line) — P-CAB — faster, longer acid suppression than PPI; superior HP eradication in resistant cases (ACG 2024)

Setting playbook (outpatient) — Diagnose PUD (EGD vs HP test-and-treat per age/alarm features), HP eradication if positive, healing PPI course, NSAID review, recurrence prevention (ACG 2024)
5. PPI healing course Omeprazole 20-40 mg PO daily × 4w (duodenal) / 8-12w (gastric) PO daily — PUD diagnosed (ACG 2024) (ACG 2024)
6. HP eradication if HP+ Bismuth quad 14d OR concomitant quad 14d OR vonoprazan-amoxicillin dual 14d PO per regimen — HP positive (ACG 2024) (ACG 2024 / Maastricht VI)
7. PPI co-prescription on antiplatelet/OAC Omeprazole 20 mg PO daily PO daily — On DAPT/OAC with prior PUD (ACG 2024) (COMPASS/COGENT (ACG 2024))
8. NSAID withdrawal or COX-2 substitution Stop NSAID OR celecoxib 100-200 mg BID with PPI PO BID — NSAID essential (ACG 2024) (Reduce GI risk (ACG 2024))

Non-pharmacologic actions:
- EGD if alarm features OR age ≥60 with new dyspepsia (ACG 2024)
- HP test-and-treat if <60 + no alarm features (ACG 2024)
- Smoking cessation (ACG 2024)
- Alcohol moderation (ACG 2024)
- Avoid NSAIDs (ACG 2024)
- HP eradication test 4 weeks post-treatment (off PPI 2w) (ACG 2024)
- Repeat EGD 8-12 weeks for gastric ulcer (mandatory; biopsy malignancy) (ACG 2024)

AVOID / contraindication checks:
- NSAID_avoid_in_PUD_history (ACG 2024)
- Clarithromycin_avoid_macrolide_resistance_>15% (ACG 2024)
- Metronidazole_no_alcohol (ACG 2024)
- Tetracycline_avoid_pregnancy (ACG 2024)
- Rifabutin_check_drug_interactions (ACG 2024)
- Vonoprazan_caution_severe_hepatic_impairment (ACG 2024)

Monitoring

Regimen monitoring:
- HP eradication test 4w post Rx off PPI 2w (ACG 2024)
- repeat EGD 8 to 12w for gastric ulcer mandatory biopsy for malignancy (ACG 2024)
- gastrin q6 12mo if ZES (ACG 2024)
- PPI long term safety review annually B12 Mg Ca CDI AKI (ACG 2024)
- serial CBC for bleeding monitoring (ACG 2024)

Setting (outpatient) monitoring:
- 4w symptom check + HP eradication test (ACG 2024)
- 8-12w repeat EGD for gastric ulcer (ACG 2024)
- Annual PPI safety review (ACG 2024)

Follow-up plan: 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)
- Close-out criterion: follow-up scheduled

Monitoring phase: 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)

Disposition

Current setting: outpatient — Diagnose PUD (EGD vs HP test-and-treat per age/alarm features), HP eradication if positive, healing PPI course, NSAID review, recurrence prevention (ACG 2024)

Disposition criteria:
- Continue PPI healing if responding (ACG 2024)
- EGD/biopsy at 8-12 weeks for gastric ulcer (ACG 2024)
- Refer GI for refractory or complicated disease (ACG 2024)

Escalation triggers (move to higher acuity):
- Hematemesis / melena → ED / UGIB pathway (ACG 2024)
- Acute abdomen / perforation → ED / surgery (ACG 2024)
- Refractory symptoms despite PPI + eradication → fasting gastrin / EGD + ZES workup (ACG 2024)

Patient Action Plan

**Peptic ulcer disease — recurrence prevention plan (ACG 2024)**
Personalised values: HP_status (ACG 2024), NSAID_or_aspirin_use (ACG 2024), anticoag_OAC_use, prior_bleeding.

**Healed and protected (ACG 2024)** (green):
Triggers:
- No epigastric pain or dyspepsia
- Tolerating regular diet
- HP eradication confirmed (if applicable)
- On PPI co-prescription if on antiplatelet/OAC
Actions:
- Take PPI as prescribed (do not skip)
- Avoid NSAIDs and ibuprofen unless approved with PPI
- No smoking, moderate alcohol
- Keep follow-up EGD if gastric ulcer (8-12w)
- HP retest at 4 weeks if treatment course completed

**Caution — call provider within 24 hours (ACG 2024)** (yellow):
Triggers:
- Returning epigastric pain or dyspepsia despite PPI
- Mild nausea or early satiety
- New iron deficiency symptoms (fatigue, pallor)
- Inadvertent NSAID use
Actions:
- Continue PPI as prescribed
- Avoid NSAIDs, alcohol
- Consult clinician about symptom return
- Possible HP retest or EGD
Contact provider when:
- Symptoms not improving on PPI
- New anemia symptoms
- NSAID exposure with prior PUD

**Medical alert — go to ED now (ACG 2024)** (red):
Triggers:
- Vomiting blood or coffee-ground material
- Black tarry stool or red blood per rectum
- Severe abdominal pain that gets worse
- Sudden severe abdominal pain with rigid belly (perforation)
- Lightheadedness or fainting
Actions:
- Call 911 / go to nearest ED immediately
- Bring updated medication list (especially NSAID/aspirin/anticoag)
Contact provider when:
- Any red zone symptom — ED now, do not wait

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Free air on upright CXR / CT + peritoneal signs (ACG 2024)
- [SEVERE] Forrest Ia (active spurting), Ib (oozing), IIa (visible vessel) on EGD (ACG 2024)
- [MODERATE] HP positive after 2 prior eradication attempts (ACG 2024)

Citations

- ACG 2024 H. pylori Guideline (Chey) + Maastricht VI / Florence 2022 + ACG 2021 UGIB (Laine) + AGA 2024 PPI Use Guidance + COMPASS + COGENT + SUP-ICU [PMID:28071659](https://pubmed.ncbi.nlm.nih.gov/28071659/)
- Cited evidence (PMID 35944925) [PMID:35944925](https://pubmed.ncbi.nlm.nih.gov/35944925/)
- Cited evidence (PMID 21060077) [PMID:21060077](https://pubmed.ncbi.nlm.nih.gov/21060077/)

Last reconciled with current guidelines: 2026-05-22.
References
  • ACG 2024 H. pylori Guideline (Chey) + Maastricht VI / Florence 2022 + ACG 2021 UGIB (Laine) + AGA 2024 PPI Use Guidance + COMPASS + COGENT + SUP-ICU — PMID:28071659
  • Cited evidence (PMID 35944925) — PMID:35944925
  • Cited evidence (PMID 21060077) — PMID:21060077