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.

Crohn's Disease


Related Terms

  • Enteritis
  • Ileitis
  • Regional Enteritis

Differential Diagnosis

Specialists

  • Colon and Rectal Surgeon
  • Gastroenterologist
  • General Surgeon

Comorbid Conditions

  • Psychiatric disorders

Factors Influencing Duration

The length and frequency of disability will depend on several factors: the degree of inflammation, the amount of chronic bleeding, the individual's nutritional state, and the extent to which an individual's disease can be controlled through diet and medication. If abscesses, obstructions, or fistulas are present, surgery may be needed. Although surgery results in immediate disability, the potential for greater symptomatic relief may decrease future disability. Complications such as renal calculi, gallstones, liver disease, or other extra-intestinal manifestations may increase duration.

Smoking has been found to increase the recurrence rate of Crohn's disease.

Medical Codes

ICD-9-CM:
555.0 - Regional Enteritis, Small Intestine; Ileitis
555.2 - Regional Enteritis, Small Intestine with Large Intestine
555.9 - Regional Enteritis of Unspecified Site; Crohns Disease NOS

Overview

© Reed Group
Crohn's disease (CD) is a type of chronic inflammatory bowel disease. It involves the formation of areas of patchy inflammation, primarily in the small intestine (terminal ileum) but sometimes in other parts of the digestive tract, including the mouth, esophagus, stomach, and colon. Where inflammation exists, it extends into all the tissue layers of the intestinal wall (mucosa). The classic symptoms are diarrhea, abdominal pain, fatigue, fever, and sometimes gastrointestinal bleeding. However, bleeding is not as common or severe as in other forms of inflammatory bowel disease, and perforation of the intestinal wall also occurs less often in CD.

In the clinical course of Crohn's disease, lesions form at the site of inflammation in the intestinal wall crypts, and they develop into ulcerations. Ulcerated areas thicken the bowel wall and narrow the diameter of the intestinal tract (lumen), leading to obstruction, abscess formation, scarring (adhesions) and decreased ability of the intestinal wall to absorb nutrients (malabsorption). Malnutrition, dehydration, and nutritional deficiencies can result. Malabsorption of fats and bile acids results in deficiencies of fat-soluble vitamins and gallstone formation (cholelithiasis) caused by elevated cholesterol in the bile. If fat malabsorption also traps calcium, oxalate combines with sodium, forming sodium oxalate, which is soluble and is absorbed into bloodstream from the colon. In the kidney, oxalate combines with calcium, leading to the formation of kidney stones (renal calculi). Ultimately CD can lead to more serious symptomatic conditions such as fibrosis and bowel obstruction.

Although Crohn's disease is chronic and usually lifelong, inflammation may be intermittent; the individual can be in remission with no symptoms for long periods.

The cause of CD is unknown (idiopathic), but an abnormality of the intestinal immune system with an imbalance between pro-inflammatory and anti-inflammatory mediators has been proposed as the etiology. Because the disease seems to run in families, there may be a genetic component as well. Stress is believed to aggravate the disease. A combination of causes has been implicated in developing the disease, including genetic, biochemical, bacterial, immunologic, environmental, dietary, vascular, and psychosocial influences (Wu).

Incidence and Prevalence: The incidence rate for Crohn’s disease in the US is about 7 cases per 100,000 population (Wu). This represents a small percentage of the 70 to 150 cases of inflammatory bowel disease per 100,000 population (Shapiro). Increases in CD have been noted in the past 5 decades, especially in northern climates. Prevalence is estimated to be higher in urban areas than in rural areas and higher among upper socioeconomic groups than lower socioeconomic groups (Wu).

Incidence in Europe ranges from 0.7 to 9.8 cases per 100,000 population, with lower rates in Asia (0.5 to 4.2 per 100,000); even lower rates are found in South Africa and Latin America (Wu).

Source: Medical Disability Advisor



Causation and Known Risk Factors

CD affects women slightly more often than men and typically develops before the age of 30 years, although it is rare in children (Shapiro). It is 4 times more common in whites than in blacks or Asians (Shapiro). Smoking has been suggested as a risk factor, particularly for prolonging the disease.

Source: Medical Disability Advisor



Diagnosis

History: Symptoms vary according to the severity of the disease, location of the inflammation, and whether intestinal or extra-intestinal complications have developed. Typically an individual experiences intermittent periods of diarrhea, pain in the abdomen, weight loss, fatigue, and fever. Sometimes, symptoms develop outside the digestive tract: joint pain, swelling, and tenderness are common extra-intestinal symptoms. It is important to ascertain a family history of CD or inflammatory bowel disease.

Physical exam: The examination of the abdomen may reveal tenderness, distention, or a mass in the lower right quadrant. During periods of partial obstruction or bloody diarrhea, excessive bowel sounds may be heard. Ulcers may be found in the mouth, and rectal examination may reveal abscesses, abnormal passageways due to erosion of the intestine (fistulas) or adhesions near the anus and rectum (perianal region).

Increased heart rate (tachycardia) may be noted. The inside of the mouth (oral mucosa) may be pale if anemia is present. The tongue may be inflamed (atrophic glossitis) and ulcerated areas may be seen in the mouth.
Examination of the eyes may reveal uveitis or inflammation of connective tissue (episcleritis).

Joint involvement may be found, as well as enlargement of the liver and spleen (hepatosplenomegaly). There may be areas of inflammation on the back of the legs (erythema nodosum).

Tests: Barium contrast x-rays taken of the intestine reveal patchy areas of inflammation ("cobblestone" appearance), ulcers, narrowing (strictures), or fistulas.

Endoscopy of the small intestine (esophagogastroduodenoscopy) or colon (colonoscopy) enables visualization of these intestinal abnormalities. Thick, firm areas of inflammation (granulomas) or ulceration may be discovered. Biopsy of these areas can confirm the diagnosis.

Laboratory tests are done to measure and monitor the effects of inflammation, such as anemia, infection, and malabsorption. An increased erythrocyte sedimentation rate (ESR) and an elevated C-reactive protein test (CRP) indicate active inflammation. Inflammatory mediators may be evaluated by testing for interleukin-1 and tumor necrosis factor (TNF-alpha). Microbiologic cultures of abscesses or material from inflamed areas may disclose a bacterial or parasitic infection.

A complete blood count (CBC) will be done. An increased white blood cell count (WBC) indicates inflammation and possible infection. The CBC will include a red blood cell (RBC) count, which may be lower than normal. Chronic bleeding may lead to anemia. Hematocrit and hemoglobin will be determined and may be lower than normal if anemia is present. Chronic diarrhea results in low blood levels of potassium, magnesium, calcium, and albumin, which can be identified with blood chemistries. Liver enzymes also may be measured. Malabsorption results in low vitamin B12 and folate levels. A positive fecal occult blood test (FOBT) indicates hidden blood in the stool, usually a sign of chronic intestinal bleeding.

Source: Medical Disability Advisor



Treatment

Crohn's disease cannot be cured, but its symptoms can be controlled through medication, nutrition, diet modification, and sometimes surgery.

The first objective of treatment is to control inflammation and the intestinal immune system. Without reducing inflammation, malabsorption will continue. Anti-inflammatory drugs of the 5-amino salicylic acid group are given to reduce inflammation. Corticosteroids may be given to reduce inflammation during an acute attack but are given for only a few months at a time because they may cause significant long-term adverse effects. Immunosuppressive drugs are given to help relieve symptoms in individuals with severe progressive disease who have not responded to other treatments.

Nutrition is important in CD, so a diet adequate in calories, vitamins, and protein is recommended. Diet modification varies according to the symptoms of the disease. During periods of diarrhea, a low-fat, high-fiber diet should be followed. In contrast, early in the relapse of the disease, or if symptoms of obstruction are present, a low-fiber diet is needed. During acute stages of the disease or flares, no food should be taken by mouth in order to rest the colon.

Sometimes, especially with advanced disease, nutritional supplementation is needed. Nutrients may be placed directly into the stomach or intestine through a tube (enteral therapy) or into the bloodstream intravenously (total parenteral nutrition, or TPN).

Iron may be needed to treat anemia, and vitamin B12 injections may be needed to reverse malabsorption, particularly if there is advanced disease of the small intestine. When abscesses are present, antibiotics are given to fight the infection. Bile salt binding agents or other antidiarrheal medications may be helpful during episodes of diarrhea but should be used with caution.

Surgical removal of a portion of the intestine (resection) may provide significant relief. However, many patients need a second or third procedure. In cases of severe disease, the entire colon may be removed (colectomy). The disease often recurs after surgery near the resection site or in other sites of the intestine. Depending on how much of the intestine is removed, a temporary or permanent passageway may need to be created through which waste materials can be removed from the body (ostomy). Surgery also may be needed to remove a fistula (fistulectomy) or to open an obstructed portion of the intestine (stricturoplasty).

Living with Crohn's disease is challenging. Psychotherapy or participation in a support group may help the individual cope with the particular difficulties of Crohn's disease and the general difficulties of chronic disease.

Source: Medical Disability Advisor



Prognosis

With medical and surgical management, individuals with Crohn's disease can function normally throughout a long life. The disease will have periods of exacerbation and periods of remission but typically does not lead to death.

Drug treatment can be effective, but results for some complications may not be evident for a long time. For example, drug treatment for fistulas may take 3 to 6 months. For some individuals, surgery brings symptomatic relief that lasts from 5 to 15 years.

Source: Medical Disability Advisor



Complications

Inflammation can lead to stricture and obstruction of the intestines, the development of fistulas leading from the intestine to another part of the body such as the skin, bladder, vagina, or another portion of the intestine, and abscesses, particularly in the perianal region (e.g., anal fissures, perianal fistulae). Repeated excision of obstructed segments of intestine can lead to short bowel syndrome, which exaggerates the symptoms of diarrhea, weight loss, and malnutrition.

The formation of clots (thromboembolism) occurs in 30% of individuals with Crohn’s disease, which can increase morbidity and mortality, especially in individuals who are immobile, who smoke tobacco, are on steroid therapy, or who undergo surgery for any reason (Wu).

Although uncommon, bleeding from inflamed areas may develop into severe hemorrhage. Inflammation, ulceration, and thickening of the wall of the intestines make it difficult for nutrients to be absorbed through the wall of the small intestine, possibly leading to malnutrition. The colon may expand and develop into a condition known as toxic megacolon. Urinary tract involvement may include development of renal calculi as a result of excess absorption of oxalate. Liver involvement can begin with increased production of liver enzymes and progress to autoimmune hepatitis or cirrhosis. Inflammation of the gall bladder (cholangitis) and development of gallstones (cholelithiasis) due to malabsorption of bile salts also are common in individuals with CD.

Individuals with CD may develop other inflammatory disorders outside the gastrointestinal tract, such as autoimmune disorders (e.g., ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and rheumatoid arthritis), arthropathies, skin problems such as erythema nodosum, eye conditions such as uveitis, and mouth inflammation and ulcer formation. Crohn's disease increases the risk of colon cancer, which significantly influences the severity of the disease.

The long-term use of corticosteroids to reduce inflammation of the bowel may cause osteoporosis, cataracts, diabetes, hypertension, and aseptic necrosis of the hip.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Flexible and private lavatory access may be needed, particularly during periods of exacerbation. Severe attacks may require a lighter work assignment or time off for recovery or hospitalization. If surgery is performed, heavy lifting may need to be restricted for a variable period contingent upon the magnitude of the procedure. Company policy on medication usage should be reviewed to determine if 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, or individual's family, have a history of Crohn's disease or other inflammatory bowel disease (e.g., ulcerative colitis)?
  • Does individual complain of intermittent periods of diarrhea, pain in the lower right abdomen, weight loss, fatigue, and / or fever?
  • Has individual experienced symptoms outside the digestive tract (extra-intestinal), such as pain, swelling, and tenderness in the joints?
  • Does individual complain of sores in the mouth and an inflamed tongue?
  • Were barium contrast x-rays taken of the intestine?
  • Was endoscopy of the small intestine (esophagogastroduodenoscopy) or colon (colonoscopy) done?
  • Was a tissue sample (biopsy) of the intestine taken to confirm the diagnosis?
  • Was a CBC done to detect anemia or infection?
  • Were an ESR and CRP done to verify an active inflammation?
  • Were electrolytes (i.e., sodium, potassium, chloride, calcium) measured to determine if they are imbalanced due to diarrhea?
  • Were liver enzymes measured to evaluate liver function?
  • Were special assays performed to determine the levels of interleukin-1 and tumor necrosis factor (TNF-alpha)?
  • Were vitamin B12 and folate levels tested to determine if the individual has a malabsorption problem?
  • Was a stool sample tested for occult blood? Has the presence of chronic bleeding been confirmed?
  • Have abscesses been cultured to determine if bacterial infection is present?
  • Have other conditions with similar symptoms been ruled out?

Regarding treatment:

  • Is individual on a diet that is adequate in calories, vitamins, and protein?
  • Is individual compliant with the diet and supplement regimens?
  • If the disease is advanced, is the individual receiving nutritional supplementation, such as enteral therapy or TPN?
  • Is individual taking anti-inflammatory medication or corticosteroids? Has the individual responded to the medication?
  • If individual has not responded to anti-inflammatory drugs, does individual require immunosuppressive drugs?
  • If individual is has iron deficiency anemia, folate deficiency, or pernicious anemia, are supplemental iron, folate, or vitamin B12 being taken, respectively?
  • Does individual require surgery to remove part or the entire colon (partial or total colectomy, respectively)?
  • Was a temporary or permanent colostomy performed? Would individual benefit from psychotherapy and / or participation in a support group to cope with the illness?

Regarding prognosis:

  • Has individual experienced short- or long-term adverse effects from the medication?
  • Is individual malnourished, prolonging recovery?
  • Does individual smoke, complicating recovery?
  • Did individual require surgery to alleviate symptoms of the disease? If so, what surgery was required? Were there any postsurgical complications?
  • Has individual experienced stricture or obstruction of the intestines? Is individual a candidate for surgical correction of these problems?
  • Have fistulas developed from the intestine to another part of the body?
  • Has individual developed renal calculi, gallstones, liver disease, or kidney disease?
  • Are anorectal complications present such as fistulas and abscesses?
  • Has thromboembolism occurred, and is it being treated?

Source: Medical Disability Advisor



References

Cited

Shapiro, William. "Inflammatory Bowel Disease." eMedicine. Eds. William K. Chiang, et al. 25 Apr. 2008. Medscape. 19 Jul. 2009 <http://emedicine.medscape.com/article/774566-overview>.

Wu, George Y., Marcy L. Coash, and Senthil Nachimuthu. "Crohn Disease." eMedicine. Eds. Waqar A. Qureshi, et al. 20 Jan. 2009. Medscape. 19 Jul. 2009 <http://emedicine.medscape.com/article/172940-overview>.

Source: Medical Disability Advisor






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