Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Anal Fissure and/or Rectal Ulcer


Related Terms

  • Anal Fistula
  • Anal Tear
  • Fissure-in-Ano
  • Fistula-in-Ano
  • Rectal Ulcer

Differential Diagnosis

  • Acquired immune deficiency syndrome (AIDS)
  • Carcinoma
  • Colitis
  • Crohn's disease
  • Diverticulitis
  • Hemorrhoids
  • Inflammatory bowel disease
  • Intersphincteric abscess
  • Leukemia
  • Malignant melanoma
  • Proctitis
  • Syphilis (primary chancre)

Specialists

  • Colon and Rectal Surgeon
  • Gastroenterologist
  • General Surgeon

Comorbid Conditions

Factors Influencing Duration

Duration may be influenced by the condition's underlying cause, the fissure's extent and severity, and whether a medical or surgical approach is used for treatment.

Medical Codes

ICD-9-CM:
565.0 - Anal Fissure, Traumatic
569.41 - Ulcer of Anus and Rectal

Overview

Anal fissures and rectal ulcers are painful tears, splits or cracks (linear ulceration or laceration) in the mucous membrane, extending from the anal sphincter upward into the anal canal.

Primary fissures are caused by direct trauma to the anal canal, as sometimes happens with passage of a large, hard stool. Secondary fissures can originate from underlying diseases such as inflammation of the lining of the rectum (proctitis), inflammatory bowel disease (Crohn's disease, ulcerative colitis), leukemia, or cancer (carcinoma). In rare cases, syphilis or tuberculosis may be the underlying cause.

Anal fissures also may be linked to low fiber diets causing constipation, physical abnormalities (hypertonicity, hypertrophy) within the internal anal sphincter, or rectal sexual intercourse. Insertion of a foreign object through the anus into the rectum also can cause the condition.

Most anal fissures are relatively minor and sporadic (acute), healing on their own. In some cases, the condition progressively worsens and leads to painful spasms within the anal sphincter. Spasms reduce blood flow to the area (ischemia), decreasing capacity to heal. An ongoing (chronic) condition then develops, with the patient fearing or avoiding bowel movements that cause even more sharp pain. In a chronic case, the sphincter may develop thickening where the tear has occurred.

About 90% of anal fissures are in the back (posterior) location of a direct line (midline) leading from the anal sphincter into the anal canal. Front (anterior) fissures are more common in women, usually because of childbirth. In women, up to 10% of fissures will be found anteriorly, whereas in men only 1% occur in this location. In about 2% of all cases, anal fissures occur both in posterior and anterior locations along the midline of the anal canal (Poritz). When fissures do not follow a direct line in the anal canal and instead are found off to the side, an underlying cause such as a sexually transmitted disease (STD) might be considered.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Anal fissures are more likely to occur in younger and middle-aged individuals, and occur with the same frequency in both sexes (Poritz). Women who have undergone childbirth have an increased risk of developing anal fissures.

Source: Medical Disability Advisor



Diagnosis

History: Individuals usually report a sharp burning, tearing, or throbbing pain during and soon after a bowel movement. Scant traces of bright red blood may be found on the toilet paper or in the toilet bowl in about 70% of individuals (Poritz).

Physical exam: A visual inspection often accomplished by gentle eversion of the anal verge with lateral traction on the buttocks is the best method of identifying an anal fissure. Because touching the fissure can cause pain and resulting spasm in the anal canal, a topical anesthetic may be required. In chronic cases, small growths of tissue (skin tags) and a hypertrophic anal papilla may be observed in association with fissures. This can lead to a misdiagnosis of hemorrhoids.

Tests: A flexible fiber-optic microscope (endoscope) may be used to visually examine the anus and lower rectum (anoscopy) in order to confirm the diagnosis of fissure. Other associated conditions, such as hemorrhoids or inflammatory bowel disease, may also be identified during this procedure.

Laboratory tests usually are not required for typical anal fissures occurring in the midline of the anal canal. Unusual fissures found in odd shapes or outside the midline of the rectum might call for laboratory tests including analysis of evidence of systemic inflammation (erythrocyte sedimentation rate, ESR), tests for human immunodeficiency virus (HIV) or other viruses, and / or analysis of microorganisms (culture) from blood, stool or urine samples to test for presence of infectious diseases. These tests can rule out inflammatory bowel diseases (Crohn's disease), cancer or acquired immune deficiency syndrome (AIDS).

Source: Medical Disability Advisor



Treatment

Fissures can be treated with ointments, warm sitz baths, high-fiber diet, increased fluid intake, and stool softeners (if constipation is present). Recently developed treatments include topical application of ointment that increases the blood flow (nitroglycerin) or injection of a drug (botulinum toxin) into the anal tissue to relax the anal sphincter. The nitroglycerin ointment is controversial because it commonly causes unpleasant side effects such as dizziness or headaches. A different topical ointment that also increases blood flow (calcium channel blocker) is gaining more widespread acceptance because of fewer side effects. Topical muscle relaxants and / or anesthetic ointment for pain relief also might be used. If these treatments are ineffective, or if fissures are recurring and ulcerated, a procedure to enlarge the sphincter (sphincter dilation) may be used under general anesthesia. A more common and effective procedure is surgical cutting of the sphincter muscle (lateral internal sphincterotomy), which provides relief by relaxing the muscle. This surgery may be performed using local or general anesthesia.

Source: Medical Disability Advisor



Prognosis

Most of anal fissures are resolved through treatment such as warm sitz baths and high-fiber diets. But when high fiber diets have been effective and then are dropped, recurrence can be expected in the majority of individuals. Topical application of nitroglycerin or calcium channel blocker may result in reduction of anal pain and some healing. Injection of botulinum toxin into the anal tissue produces a high rate of healing during the first 3 months, although a small percentage of individuals report fecal incontinence using this treatment. If the condition recurs after 3 months following the injection, surgical options are considered. Stretching the sphincter (sphincter dilation) produces variable results, along with a relatively high incidence of gas (flatus) and incontinence in up to 27% of individuals undergoing the procedure (Poritz). Anal swelling also can be associated with this procedure. Lateral internal sphincterotomy results in a very high rate of healing in 90% of cases (Abgarian). In a small number of cases a second sphincterotomy might be required.

Source: Medical Disability Advisor



Complications

Anal fissures that do not heal promptly may develop characteristic features including a nipple-like bump (proximal papilla) at the internal start of the fissure, with another hard bump (sentinel pile) at the external end. Fissures may recur, persist, and eventually develop into anal or rectal ulcers. These may result in tissue death (necrosis) and sloughing of the anal tissue. A deep fissure involving the internal anal sphincter may result in scarring and anal narrowing (stenosis) of the anus if the condition persists.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Uncomplicated cases require no work restrictions or special accommodations. Individuals recovering from surgery may need to avoid prolonged sitting and heavy physical labor until healing is complete.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was individual constipated? Was a hard, large stool passed?
  • Does individual have rectal intercourse?
  • Has individual inserted a foreign object through the anus into the rectum?
  • Does individual have Crohn's disease or ulcerative colitis?
  • Does individual have proctitis, leukemia, cancer, syphilis or tuberculosis?
  • On exam, was the fissure identified by visual inspection?
  • Was endoscopy done?
  • Were conditions with similar symptoms ruled out?

Regarding treatment:

  • Were conservative treatments such as ointments, sitz baths, high fiber diet, and increased fluid intake tried? Were they effective? Were stool softeners needed?
  • Was it necessary to do injections, dilation, or surgery?

Regarding prognosis:

  • Is individual's employer able to accommodate restrictions if needed?
  • Does individual have any conditions that may affect ability to recover?
  • If a high fiber diet initially was effective, did the individual continue to follow it?
  • Has individual had recurrent fissures?
  • Did individual develop anal or rectal ulcers? Did stenosis of the anus occur?

Source: Medical Disability Advisor



References

Cited

Abgarian, H. "Anal Fissure and Fistula." The Practice of General Surgery. Ed. K. I. Bland. Philadelphia: W.B. Saunders, 2002. 515-525.

Poritz, Lisa S. "Anal Fistulas and Fissures." eMedicine. Eds. Danny Odell Jacobs, et al. 11 Jun. 2004. Medscape. 2 Jan. 2005 <http://emedicine.com/med/topic3532.htm>.

Source: Medical Disability Advisor






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