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.

Ascites


Related Terms

  • Hydroperitoneum

Differential Diagnosis

Specialists

  • Gastroenterologist
  • Internal Medicine Physician

Comorbid Conditions

  • Cancer
  • Heart failure
  • Kidney failure
  • Liver failure
  • Respiratory failure

Factors Influencing Duration

The underlying disease process is the key factor in determining the course and length of disability.

Medical Codes

ICD-9-CM:
789.51 - Malignant ascites
789.59 - Other ascites

Overview

The term ascites refers to abnormal fluid accumulation in the abdominal cavity (peritoneal cavity).

The most common cause of ascites is elevated pressure in the liver circulation (portal hypertension) due to liver disease such as cirrhosis. The elevated pressure causes leakage of fluid from the vessels in and around the liver into the abdominal cavity. By a similar process, severe congestive heart failure causes elevated pressure in the venous system that may also cause ascites. Ascites secondary to congestive heart failure, however, is infrequent.

In the absence of portal hypertension, ascites can be associated with disorders involving the inner lining of the abdomen (peritoneum). The role of the peritoneum is to filter fluid moving through the abdominal cavity. Damage to this membrane often results in accumulation of fluid (ascites). Abdominal tumors, particularly ovarian tumors, can spread to the peritoneum and cause ascites. Tuberculosis can infect the peritoneum and result in ascites.

Chronic renal failure (nephrotic syndrome, chronic glomerulonephritis) can also be associated with ascites. Individuals on dialysis (hemodialysis) can have ascites. Inflammation of the pancreas or gallbladder with leakage of their secretions and contents into the abdomen can result in ascites.

Less frequent causes are diseases of the small intestine where protein is chronically lost from the body. In rare cases, severe underactivity of the thyroid gland (hypothyroidism) may cause ascites. An accumulation of fluid from the lymph system can occur when the lymph circulation becomes blocked by a tumor, thereby creating an ascites called chylous ascites.

Healthy men have little or no fluid in the peritoneal cavity, while women may have small amounts of fluid near the time of their menstrual cycle. With the exception of ascites from ovarian cancer in women, the exact prevalence of each disorder causing ascites is difficult to ascertain. People with ascites should be asked about risk factors for liver diseases.

Incidence and Prevalence: Approximately 80% of all instances of ascites in the US is caused by cirrhosis, while 10% is caused by cancer (Haggerty).

Source: Medical Disability Advisor



Diagnosis

History: Individuals may report that their belts or clothes are becoming tight around the waist or they may experience a sudden weight gain. Shortness of breath or swollen ankles may be reported. The individual may complain of generalized, constant, abdominal pain or discomfort. They may reveal a history of chronic illness such as hepatitis, alcoholic liver disease, congestive heart failure, or kidney failure. If the abdomen is severely distended, the individual may have difficulty breathing, especially when lying down.

Physical exam: The exam reveals mild to marked distention of the abdomen, which may feel firm or produce a wavelike action when touched (fluid wave). If there is pre-existing liver disease, the abdominal wall veins may be distended and clearly visible. In addition, the skin may appear yellow (jaundice); small veins may be visible on the nose, cheeks and upper chest (spider angiomata); and the palms may appear red or liver-colored.

The individual may look pale with thin extremities and may have rapid respiration. Ankles may be swollen due to excess fluid (edema). The neck veins may be distended, an indication of congestive heart failure. Generalized swelling (anasarca) may be present in congestive heart failure or renal failure. A fever may be present if the ascites is due to an infectious process. Firm lymph nodes near the left clavicle or around the belly button (umbilicus) may suggest abdominal cancer.

Tests: Ultrasound imaging of the abdomen can confirm the presence of ascites. Both ultrasound and CT scan of the abdomen can be useful in identifying the cause of ascites. Withdrawing some of the ascites fluid with a needle through the abdominal wall (paracentesis) to evaluate the composition of the fluid is also useful in identifying the cause of ascites. A complete blood count may be done to determine if infection is present. Liver enzymes can confirm liver dysfunction. Elevated blood amylase levels may indicate inflammation of the pancreas. Blood urea nitrogen (BUN) and blood creatinine levels may be elevated in kidney failure.

Source: Medical Disability Advisor



Treatment

In addition to managing the underlying cause, treatment is directed at eliminating the excess fluid and preventing its reoccurrence. Initial treatment usually involves the use of diuretics. Withdrawing large amounts of the fluid through a needle (therapeutic paracentesis) can be done for those who do not respond to diuretic therapy. Those with ascites secondary to chronic liver failure may require surgical intervention to shunt ascites fluid into a large vein (peritoneovenous shunting). Another procedure done with x-ray guidance uses a catheter in the vein to place a shunt. This procedure (transjugular intrahepatic portosystemic shunt [TIPS]) has been proposed as a nonsurgical alternative to the peritoneovenous shunt in treating refractory ascites. Treatment must factor in the narrow fluid and electrolyte balances fundamental to life. Liver transplantation remains the most definitive therapy for liver disease and underlying ascites.

Source: Medical Disability Advisor



Prognosis

The predicted outcome depends on the underlying disease process. Since ascites is usually caused by a chronic, progressive disease process, the outlook is not good unless something can be done to correct the underlying disease. Of those with ascites secondary to liver failure, 50% will die within 2 years regardless of therapeutic intervention.

Therapeutic paracentesis is safe and effective in removing small to moderate amounts of ascitic fluid. Because this procedure carries the risk of abdominal infection and can cause low blood pressure or shock, it may not be appropriate for those with severe or refractory ascites. Peritoneovenous shunting is effective in reducing the ascites but carries an operative mortality rate of up to 30%. While relatively new, TIPS is a procedure that effectively reduces ascites in over 50% of the cases without the risk of surgery. However, following the TIPS procedure, over 30% developed shunt failure due to occlusion, and over 20% developed metabolic brain dysfunction (encephalopathy).

Outcome and survival vary following liver transplantation. The 6-month survival after liver transplantation in clinically stable individuals with chronic liver failure is as high as 90%. Critically ill individuals at the time of transplantation have a 6-month survival of only 65%.

Source: Medical Disability Advisor



Complications

A serious complication is spontaneous bacterial peritonitis where the ascitic fluid may become infected without any identifiable cause or reason. Another complication of ascites is the movement of ascitic fluid into the lungs (hydrothorax) which can compromise breathing and cause respiratory failure especially in those with pre-existing lung disease. A weakening and outpouching of the abdominal wall (abdominal wall hernia) may also be a complication of ascites.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

If an individual with ascites is able to work, they will most likely be restricted to sedentary work. Access to a restroom is needed for those receiving diuretic therapy. Most will require close medical follow-up with frequent trips to the doctor. Deteriorating physical and mental capacity is a potential problem in those with liver failure. Job assignments may need to be adjusted accordingly (i.e., eliminate operation of machinery). The treating physician(s) must determine further restrictions and accommodations related to the underlying cause of the ascites.

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 there evidence of portal hypertension?
  • Does individual have an abdominal or ovarian tumor?
  • Does individual have tuberculosis that has infected the peritoneum?
  • Was individual on dialysis? Have nephrotic syndrome? Chronic glomerulonephritis?
  • Was there inflammation of the pancreas or gallbladder?
  • Does individual have severe hypothyroidism?
  • Was there sudden weight gain? Belt or clothes suddenly too tight?
  • Does individual complain of generalized, constant, abdominal discomfort or pain?
  • Was there a history of chronic illness such as hepatitis, alcoholic liver disease, congestive heart failure, or kidney failure?
  • Does individual have difficulty breathing especially when lying down?
  • On exam, was individual's abdomen distended? Firm? Was a fluid wave present?
  • Are the veins of the abdominal wall distended? Is jaundice present? Spider angiomata?
  • Do individual's palms appear red or liver-colored?
  • Does individual look pale? Have thin extremities? Rapid respirations? Were the neck veins distended? Was there fever? Enlarged lymph nodes?
  • Was generalized swelling (anasarca) present?
  • Was abdominal ultrasound performed? CT? Was a paracentesis done and fluid analyzed? Was blood work, including CBC, liver enzymes, amylase, BUN, and blood creatinine, done?
  • Were conditions with similar symptoms ruled out?

Regarding treatment:

  • What is the underlying cause of the ascites? Is it being treated?
  • Were diuretics used in an attempt to drain the fluid? Was a therapeutic paracentesis done?
  • Has peritoneovenous shunting been considered? A transjugular intrahepatic portosystemic shunt (TIPS)?
  • Is individual a candidate for a liver transplant?

Regarding prognosis:

  • Can individual's employer accommodate any necessary restrictions?
  • Does individual have any conditions that may affect ability to recover?
  • Have any complications developed such as bacterial peritonitis, hydrothorax, or abdominal wall hernia?

Source: Medical Disability Advisor



References

Cited

Haggerty, Maureen. "Ascites." Hendrick Health Systems. 21 Sep. 2004 <http://www.ehendrick.org/healthy/000148.htm>.

Source: Medical Disability Advisor






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