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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.

Cholecystitis


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Medical Codes

ICD-9-CM:
574.01 - Calculus of Gallbladder with Acute Cholecystitis, with Obstruction
575.0 - Cholecystitis, Acute; Abscess of Gallbladder, without Mention of Calculus; Angiocholecystitis without Mention of Calculus, Empyema or Gangrene of Gallbladder without Mention of Calculus
575.1 - Cholecystitis, Other Chronic without Mention of Calculus
575.10 - Cholecystitis, Unspecified
575.11 - Chronic Cholecystitis
575.12 - Acute and Chronic Cholecystitis
575.2 - Obstruction of Gallbladder; Occlusion, Stenosis or Stricture of Cystic Duct or Gallbladder without Mention of Calculus
575.4 - Perforation of Gallbladder; Rupture of Cystic Duct or Gallbladder
575.8 - Disorders of Gallbladder, Other Specified; Adhesions, Atrophy (of), Cyst (of), Hypertrophy (of) or Ulcer (of) Cystic Duct Gallbladder; Biliary Dyskinesia

Related Terms

  • Acalculous Cholecystitis
  • Acute Cholecystitis
  • Inflammation of the Gallbladder

Overview

Image Description:
Cholecystitis - The gallbladder appears as a small sack in the upper right abdomen. Cross-sections of two sack-like gallbladders contrast the smooth lining and bile-filled normal gallbladder with the swollen lining (mucosa) and presence of a gallstone in an inflamed gallbladder.
Click to see Image

Cholecystitis is inflammation of the gallbladder, a small pear-shaped organ in the upper right side of the abdomen just below the liver. In a healthy individual, the gallbladder stores bile produced by the liver to help the body digest fat. After a meal, particularly a high-fat meal, bile passes from the gallbladder through the cystic and common bile ducts and into the small intestine, where it helps metabolize fats. Cholecystitis generally results from obstruction of the cystic duct from gallstones (cholelithiasis) and is referred to as calculous cholecystitis, although approximately 10% of cases occur in the absence of stones (acalculous cholecystitis) (Gladden).

Cholecystitis is characterized initially by pain (biliary colic) in the upper right quadrant of the abdomen, which increases in intensity over 2 to 3 minutes and then levels off, persisting for 20 minutes or more. The pain may radiate from the abdomen to the back and/or shoulder. It generally occurs within an hour after meals and can last up to several hours. Nausea, vomiting, anorexia, and low-grade fever may also be noted. Episodes may come and go over a period of 2 to 3 days and are usually completely gone within a week.

Most cases (approximately 90% to 95%) of cholecystitis occur in individuals who have developed rock-like deposits (gallstones) in the gallbladder (Gladden), a condition called cholelithiasis. If a gallstone passes from the gallbladder into the cystic duct, blockage of the duct may cause distention of the gallbladder with decreased blood and lymphatic flow; this will trap bile in the gallbladder. The trapped bile irritates the walls of the gallbladder and creates an ideal environment for growth of infection-causing bacteria. Secondary bacterial infection occurs in up to 75% of those with acute cholecystitis, usually caused by Escherichia coli, klebsiella, or streptococcus organisms (Caddy).

Pressure from bile build-up also may result in rupture (perforation) of the gallbladder. As the immune system responds to irritation and/or infection, the gallbladder becomes inflamed, resulting in acute cholecystitis. This acute condition can become chronic with repeated flare-ups, especially in individuals who consume a diet high in fats, or who have a high level of lipids (fats) in the blood (hyperlipidemia), diabetes mellitus, or chronic alcoholism. Acute cholecystitis occasionally may occur in pregnancy accompanied by biliary colic, recurrent symptoms, and sometimes premature delivery. In chronic cholecystitis, the walls of the gallbladder gradually thicken, and the gallbladder eventually shrinks and no longer performs its function.

In some individuals, including pregnant women, those who have lost weight rapidly, or those who are nourished through a feeding tube (parenteral nutrition) or intravenously, gallbladder emptying is impaired, and bile may produce a thick, insoluble material known as gallbladder sludge which irritates gallbladder walls in much the same way as trapped bile does. Trauma to the body such as physical trauma (e.g., explosion or other accident), Salmonella poisoning, sepsis (systemic infection) and other infections, intravenous narcotic usage, or cardiac surgery can result in cholecystitis without the presence of gallstones (acalculous cholecystitis). This type of cholecystitis occurs in up to 10% of cholecystitis cases (Caddy; Gladden). It is serious and is associated with an increased risk of complications including death. Other causes include a growth (neoplasm) in the common bile duct, narrowing (stricture) of the common bile duct, or a loss of blood flow (ischemia) to the gallbladder wall. Ischemia is seen in a smaller number of cases occurring primarily in individuals with diabetes. Cholecystitis can also result if the gallbladder becomes twisted, although this is also uncommon.

While most individuals with gallstones (about 80%) remain asymptomatic; acute cholecystitis may develop in as many as one third of adults with gallstones (Caddy). Risk for developing cholecystitis is highest among individuals having a prior personal or family history of gallstones or cholecystectomy.

Incidence and Prevalence: Cholelithiasis and cholecystitis are relatively common conditions. Approximately 10% to 20% of Americans have gallstones and one-third develop acute cholecystitis (Gladden). The incidence of cholelithiasis is high among Native American, Scandinavian, and Hispanic populations (Gladden). Incidence is higher among whites than blacks in the US (Gladden).

Source: Medical Disability Advisor



Diagnosis

History: Individuals with acute cholecystitis often complain of pain or discomfort in the upper right abdomen in the area of the liver and gallbladder or just under the breastbone. Pain may radiate to the back and shoulder area and may be associated with nausea and vomiting, anorexia and fever. The individual may report several days or weeks of recurring symptoms that tend to occur within an hour after meals, gradually increasing in intensity to become constant, then leveling off and persisting for up to several hours or days.

Individuals with chronic cholecystitis may complain of vague abdominal pain and mild indigestion (dyspepsia) following fatty meals. They may also complain of nausea and an increased frequency of belching. They often will report a history of gallstones and related biliary colic.

Physical exam: The individual may have a mild-to-moderate fever indicative of infection. Pressing on (palpating) the abdomen in the area of the gallbladder and liver may reveal local tenderness. While palpating this area, the physician may ask the individual to take a deep breath. If inhalation stops when the area is pressed, this is known as a positive Murphy's sign and is characteristic of acute cholecystitis. An enlarged gallbladder palpated in some cases. Some individuals may have jaundice, a yellowish discoloration of the skin and whites of the eyes (sclerae). Some patients, especially the elderly and diabetics, may have atypical findings.

Tests: Blood tests are ordered to determine the white blood cell count (WBC) as an indication of infection; bilirubin, alkaline phosphatase and liver enzymes to evaluate liver function; amylase and lipase to screen for pancreatitis; C-reactive protein, and erythrocyte sedimentation rate (ESR) to check for signs of inflammation; and urinalysis to rule out renal colic. Nevertheless, laboratory tests can be normal in some cases. Pregnancy testing should be considered in women of childbearing age. X-ray is commonly obtained in the absence of pregnancy to help the physician rule out other conditions such as gallbladder cancer (calcified or porcelainized gallbladder), intestinal obstruction, or renal stones. Transabdominal ultrasound (TUS) will likely be performed to visualize the gallbladder and determine the presence of gallstones. This imaging technique has high specificity (98%) for diagnosing cholecystitis (Caddy). TUS may also show thickening of the gallbladder wall, stretching (distention) of the gallbladder, and the presence of gallbladder sludge. If ultrasound is not diagnostic, hepatobiliary scintigraphy (hepatoiminodiacetic acid [HIDA] scan) may be used to examine the cystic duct for possible obstruction This test is 95% accurate in diagnosing acute cholecystitis (Gladden). CT or MRI may be requested as well to confirm the diagnosis or rule out other conditions, especially if ultrasound and HIDA are inconclusive.

Source: Medical Disability Advisor



Treatment

Acute cholecystitis with mild symptoms can be treated conservatively with dietary restriction, analgesics, antibiotics, and follow-up monitoring.

When moderate to severe pain is present, the individual often is admitted to the hospital for intravenous medication and fluids. Medication may include pain relievers (analgesics), antiemetics for nausea and vomiting, and antibiotics. The individual will not be able to receive food by mouth, and a tube may be passed from the nose into the stomach to keep the stomach empty and prevent stimulation of the gallbladder while providing intravenous hydration.

Surgical removal of the gallbladder (cholecystectomy) is the treatment for symptomatic cholecystitis. The preferred technique is laparoscopic cholecystectomy, a minimally invasive procedure performed in about 90% of cases (Gladden). In this procedure, a thin tubular fiber-optic instrument (laparoscope) with a tiny camera attached is inserted through a small abdominal incision, allowing the surgeon to view the gallbladder and perform the surgery. The surgeon incises the gallbladder and removes it using tools passed through another small incision. Patients with suspect perforation, cancer, very large stones, end stage liver disease, bleeding disorders, and some with morbid obesity are not candidates for laparoscopic cholecystectomy.

In an open surgical procedure, a larger incision is made in the abdomen to expose the gallbladder and incise it. Open surgical removal of the gallbladder is performed most often when complications such as perforation of the gallbladder or scarring from previous surgery are encountered during a laparoscopic procedure. Open surgery is needed if the gallbladder has perforated. During cholecystectomy, gallstones often are found within the common bile duct (choledocholithiasis). Stone removal with endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy is an option to treat common bile duct stones or, if the gallbladder is intact, the surgeon may prefer cholecystectomy and exploration of the bile duct.

Treatment of any underlying illness, such as diabetes, pancreatitis, sepsis, hemoglobinopathies, or dehydration is an important aspect of treatment of cholecystitis. If an underlying illness would increase the risks of surgery, surgery can be delayed while that illness is treated; however complicated cases such as acalculous cholecystitis may require immediate emergency surgery.

Source: Medical Disability Advisor



Prognosis

The prognosis for cholecystitis is favorable in the majority of cases. Cholecystectomy (either laparoscopic or open surgery) is associated with a 0.1% mortality rate in individuals under 50 years of age and 0.8% in those over age 50 (Gladden). The less invasive laparoscopic procedure is associated with less pain, a shorter hospital stay, and a shorter recovery period than the open procedure. Cholecystectomy provides a complete resolution of symptoms in 75% to 90% of cases. After cholecystectomy, gallstones may occur in the bile ducts, a condition known as choledocholithiasis.

In cases in which cholecystitis is treated nonsurgically (conservatively) with medication only, 25% of individuals will have another episode of acute cholecystitis within 1 year, and 60% will have another episode within 6 years (Gladden).

Complicated cases of cholecystitis such as critically ill patients, those with perforated gallbladder, acalculous cholecystitis, gangrenous cholecystitis, secondary pancreatitis, or sepsis have a less favorable prognosis, with mortality as high as 50% to 60% depending on the specifics of the complication (Gladden).

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Gastroenterologist
  • General Surgeon

Source: Medical Disability Advisor



Comorbid Conditions

Source: Medical Disability Advisor



Complications

Complications in cholecystitis cases include perforation of the gallbladder; abscess formation in the gallbladder; development of an abnormal tube-like passage (fistula) from the gallbladder to the intestine, colon, or skin; gangrene (gangrenous cholecystitis); the presence of gas-forming organisms (e.g., Clostridium welchii or E. coli) within the wall or opening of the gallbladder, usually in diabetic or elderly individuals; pus in the gallbladder and abdominal cavity (empyema); inflammation of the bile ducts (cholangitis), liver (hepatitis), or pancreas (pancreatitis); intestinal obstruction (gallstone ileus); and cancer (neoplasm). Individuals treated without surgery are at higher risk for gallbladder perforation, which occurs in 10% of cases and has a 25% mortality rate (Gladden). Complications of laparoscopic cholecystectomy can include bleeding, pancreatitis, leakage from the duct stump, and major bile duct injury.

Source: Medical Disability Advisor



Factors Influencing Duration

The duration of recovery is affected by the severity of the individual's symptoms, the presence of infection, or other complications, and whether surgery is required. If surgery is required, the method (laparoscopic or open) of surgery, presence of surgical complications, and the individual's ability to heal also will affect the duration of recovery. If surgery is not required, recovery may vary, depending on the individual's response to any prescribed medication (e.g., non-steroidal anti-inflammatory drugs [NSAIDs], antibiotics).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals with cholecystitis can expect complete recovery following treatment. No work restrictions or special accommodations are generally required. Individuals undergoing open surgery may need to avoid heavy lifting and strenuous physical work for several weeks as they recover. Temporary assignment to a sedentary position may be helpful for individuals recovering from surgery, if their regular jobs are physically demanding. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

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:

  • Does individual have a history of multiple trauma, Salmonella poisoning, sepsis, or cardiac surgery? Obesity, diabetes, or chronic alcohol use?
  • Is individual pregnant? Has individual lost weight rapidly?
  • Does individual use oral contraceptives?
  • Does individual complain of steady pain or discomfort in the middle/upper abdomen?
  • Does the pain spread from the abdomen to the back and shoulder area?
  • Does individual report nausea, vomiting, or low fever?
  • Do the symptoms tend to occur soon after meals and ease in intensity over a period of 2 to 3 minutes?
  • Do the symptoms level off and persist for 20 minutes to an hour before beginning to subside?
  • Were blood tests done to evaluate liver function and check for signs of inflammation and/or infection? Was transabdominal ultrasound done to determine the presence of gallstones?
  • Was an x-ray or a CT scan done to help the physician confirm the diagnosis and rule out other conditions such as gallbladder cancer?
  • If a blockage of the cystic duct is suspected, was a hepatobiliary scan (HIDA) done?
  • Was the diagnosis of cholecystitis confirmed?

Regarding treatment:

  • If individual had mild symptoms, NSAIDs administered?
  • Was any infection treated with antibiotics? Was individual compliant with the medication regimen?
  • Was hospitalization required?
  • Was surgery required?
  • If surgery was necessary, was cholecystectomy done via a laparoscope, or was open surgery?
  • Is individual following diet and alcohol restrictions?

Regarding prognosis:

  • Was individual treated with medication or surgery?
  • If treatment was with medication, has another episode of cholecystitis occurred?
  • Has perforation of the gallbladder occurred?
  • If treatment was surgical, have gallstones developed in the bile ducts (choledocholithiasis)?
  • Did individual experience complications following surgery?
  • How are complications being treated? What is expected outcome with treatment?

Source: Medical Disability Advisor



References

Cited

Caddy, G. R. "Cholelithiasis and Cholecystitis." Conn's Currenty Therapy. Eds. Robert E. Rakel and Edward T. Bope. 60th ed. Philadelphia: Elsevier Saunders, 2008. 487-490.

Gladden, Don, et al. "Cholecystitis." eMedicine. 4 Aug. 2008. Medscape. 27 Feb. 2009 <http://emedicine.medscape.com/article/171886-overview>.

General

Afdhal, N. H. "Discussion of the Gallbladder and Bile Ducts." Cecil Textbook of Medicine. Eds. Lee Goldman, et al. 22nd ed. Philadelphia: W.B. Saunders, 2004.

Bilhartz, L. "A Calculus Cholecystitis, Cholesterolosis, Adenomyomatosis, and Polyps of the Gall Bladder." Sleisenger & Fordtran's Gastrointestinal and Liver Disease. Eds. M. Feldman, L. S. Friedman, and M. H. Sleisenger. 7th ed. Philadelphia: W.B. Saunders, 2002. 1116-1130.

Source: Medical Disability Advisor