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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.

Esophageal Varices


Text Only Home | Graphic-Rich Site | Overview | Diagnosis | Treatment | Prognosis | Differential Diagnosis | Specialists | Comorbid Conditions | Complications | Factors Influencing Duration | Length of Disability | Ability to Work | Maximum Medical Improvement | Failure to Recover | Medical Codes | References

Medical Codes

ICD-9-CM:
456.0 - Esophageal Varices with Bleeding
456.1 - Esophageal Varices without Mention of Bleeding
456.20 - Esophageal Varices in Diseases Classified Elsewhere; with Bleeding
456.21 - Esophageal Varices in Diseases Classified Elsewhere; without Mention of Bleeding

Related Terms

  • Bleeding Esophageal Varix
  • Esophageal Varix

Overview

Image Description:
Esophageal Varices - A frontal view of the chest highlights a portion of the lower esophagus just above its entry into the stomach. A close-up of the highlighted area shows the swollen veins of esophageal varices inside the esophagus and upper stomach.
Click to see Image

Esophageal varices are fragile, swollen veins at the base of the muscular tube (esophagus) that serves as the conduit between the mouth and the stomach.

Although varices appear in the esophagus, they are caused by disease in the liver. A condition called portal hypertension develops over months or years as the liver becomes so severely scarred (usually from cirrhosis) that blood flowing from the abdominal organs can no longer filter through the liver. The blood must go somewhere and, over time, it goes around the liver and into areas with lower venous pressures such as the small superficial veins lining the mucosa of the lower part of the esophagus that are not designed to carry large amounts of blood. These veins develop a high pressure and become distended and tortuous. If they rupture, they may bleed profusely.

In the Western Hemisphere and Europe, the most common conditions that cause portal hypertension and lead to esophageal varices are cirrhosis of the liver and portal vein blockage (thrombosis). Cirrhosis accounts for the majority of cases of portal hypertension in the US. The most common cause of cirrhosis in the US is chronic hepatitis C followed by alcoholism and cholestatic liver diseases (Johns Hopkins).

Incidence and Prevalence: Gastroesophageal varices are present in almost half of patients with cirrhosis at the time of diagnosis. The more advanced the cirrhosis, the more likely it is that the patient will present with varices. Each year approximately 12% of patients with varices will experience hemorrhage (5% for small varices and 15% for large varices). After the first episode of hemorrhage, 60% of all patients will experience another episode over the course of a year. Approximately 15% to 20% of patients will die within 6 weeks of an episode of variceal hemorrhage, those with advanced disease being far more likely to die than those with mild cirrhosis (Garcia-Tsao).

Source: Medical Disability Advisor



Diagnosis

History: Individuals with bleeding esophageal varices often vomit bright red blood or partially digested blood that resembles coffee grounds. They may be malnourished, have bloody or tarry stools, and feel dizzy and faint. A history of alcoholism can be significant. There are many other causes of gastrointestinal bleeding, but profuse bleeding in a patient with a characteristic history generally indicates ruptured varices.

Physical exam: An individual with nonbleeding varices may have signs that raise suspicion of portal hypertension and cirrhosis. Distended veins over the surface of the abdomen and large, swollen hemorrhoids are common. A shrunken, hard liver and an enlarged spleen can be felt. Some individuals lack the ability to think clearly; in conversation, they may sound unclear or even incoherent (encephalopathy). Signs of cirrhosis include abdominal fluid (ascites), endocrine changes, and skin changes. In an individual who presents with active bleeding, low blood pressure (hypotension), fast pulse (tachycardia), and shock are common.

Tests: Lab tests include a complete blood count (CBC) and liver function tests. The level of protein in the blood (serum albumin) is determined, and usually is low (hypoalbuminemia). If an individual presents with active bleeding, blood must be typed and cross-matched for transfusions.

If the individual is not bleeding at the time of examination, magnified viewing of the troubled area with a lighted scope (an upper fiberoptic endoscopy) may be performed to visualize the varices and assess the severity of the problem. Barium swallow x-rays may outline the varices.

Source: Medical Disability Advisor



Treatment

An actively bleeding individual is hospitalized in intensive care and may be given drugs intravenously to constrict the veins. Endoscopic treatment is the mainstay of the emergency treatment of bleeding varices (Grace). Injection through an endoscope of a compound to irritate the tissue cells of the vein and cause them to form scar tissue (endoscopic sclerotherapy) may be used on the problem veins and is often performed in two sessions. Another very effective method of endoscopic therapy is rubber band ligation of the varices (banding). A procedure called balloon tamponade can be effective but has a high rate of complications and is rarely used.

When bleeding is severe, the individual must be treated immediately with fluids and blood transfusions. Individuals whose blood does not clot normally require fresh frozen plasma. The first step is to stabilize the blood volume by controlling blood pressure with drugs, including intravenous vasopressin, octreotide, nitrates, or somatostatin, which decreases blood flow to the gastrointestinal tract. Drugs that lower blood pressure may also be given to reduce the risk of further bleeding. Some individuals avoid rebleeding by taking oral beta-blockers, which offer the success rate of sclerotherapy without the side effects. Nonsteroidal anti-inflammatory drugs and the anti-osteoporosis drug alendronate must be avoided because of the risk of ulceration and bleeding. If the bleeding cannot be controlled or if the individual requires more than 6 to 8 units of blood in the first 24 hours, surgery to create an artificial passageway (portal shunt) to redirect blood flow may be recommended. Nearly all types of treatment for esophageal varices have potentially serious side effects.

In some cases, liver transplantation may be considered.

Source: Medical Disability Advisor



Prognosis

Bleeding esophageal varices are a serious complication of liver disease. They carry a poor prognosis. Liver transplantation improves the prognosis, but may not be possible in very advanced cases or in individuals who continue to abuse alcohol. With successful surgical treatment (either a portal shunt or tying off the varix [banding] or sclerotherapy and strict adherence to abstinence from alcohol), the chances and severity of future bleeding episodes are reduced. Sclerotherapy stops bleeding in about 90% of cases (Zuberi). However, rebleeding is likely in most cases, usually within 6 weeks (D'Amico).

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Addiction Psychiatrist
  • Emergency Medicine Physician
  • Gastroenterologist
  • General Surgeon

Source: Medical Disability Advisor



Comorbid Conditions

  • Substance abuse and dependence

Source: Medical Disability Advisor



Complications

Rupture with bleeding of the varices is the most significant complication. Noncompliance with instructions to cease drinking alcohol and practice better nutrition may cause complications. Recurrence of bleeding after treatment, reduced blood volume (hypovolemic shock), and esophageal narrowing (stricture) after surgery are other complications.

Source: Medical Disability Advisor



Factors Influencing Duration

Continued alcohol consumption may lengthen disability and cause the condition to become permanent. Once esophageal varices have developed, the condition and its complications are permanent.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

The individual may need to be reassigned to less stressful work to help prevent the worsening of conditions that lead to esophageal varices. Individuals may need to have work scheduled such that they have time to visit physicians and therapists as necessary.

For more information regarding risk, capacity, and tolerance as they apply to liver disease, refer to "Work Ability and Return to Work," pages 363-364.

Risk: The restrictions are usually determined more by the underlying severity of the liver disease.

Capacity: Blood testing for CBC and liver function, in particular clotting proteins, as well as ammonia levels may be helpful objective criteria.

Tolerance: The tolerance is usually determined more by the underlying severity of the liver disease. In particular, progressive liver disease will cause greater fatigue.

Source: Medical Disability Advisor



Maximum Medical Improvement

Incidental discovery of non-bleeding and non-symptomatic varices can be at MMI at 14 days.

If varices are due to severe liver disease, that condition may dictate when a individual can be declared at MMI.

Sclerotherapy would put a individual at MMI at 90 days.

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 history of liver disease from alcoholism (cirrhosis)?
  • Does individual report vomiting bright red blood or partially digested blood that resembles coffee grounds?
  • Has individual noted bloody or tarry stools?
  • Does individual complain of feeling dizzy or faint?
  • Does individual or physician note distended veins over surface of abdomen and large, swollen hemorrhoids?
  • Is it difficult for individual to think clearly or to have coherent conversation (encephalopathy)?
  • Were complete blood count (CBC) and liver function tests done?
  • Was level of protein in blood (serum albumin) measured?
  • Were varices visible on endoscopy or in upper gastrointestinal x-ray (upper GI series)?
  • Was upper fiberoptic endoscopy performed to assess severity of problem?
  • Was diagnosis of esophageal varices confirmed?

Regarding treatment:

  • Does individual understand importance of complete avoidance of alcohol?
  • Was individual hospitalized?
  • Did individual receive intravenous vasopressin and nitrates or somatostatin?
  • Did individual receive beta-blockers?
  • Was medication therapy successful?
  • Was stopping blood flow to the varices (balloon tamponade) required?
  • Was injection of hardening (sclerosing) compound to irritate tissue cells of vein (endoscopic sclerotherapy) required?
  • Was endoscopic rubber band ligation of varices (banding) required?
  • Do varices continue to bleed, or was procedure successful?
  • If bleeding was severe and uncontrollable, was surgery to redirect blood flow via an artificial passageway (portal shunt) required?
  • Was blood loss extensive?
  • Did individual experience complications from severe bleeding or from surgery? Was surgery successful?

Regarding prognosis:

  • Is individual absolutely compliant with abstinence from alcohol?
  • If not, would individual benefit from counseling regarding addictive behavior?
  • Is this initial episode of bleeding esophageal varices, or is this rebleeding episode?
  • How extensive is blood loss?
  • What treatment plan is in place to address blood loss?
  • If individual had surgery, have complications arisen?
  • What treatment will be given for complications and what is expected outcome with treatment?
  • Is this patient a candidate for transplantation?

Source: Medical Disability Advisor



References

Cited

D'Amico, G., et al. "Octreotide Compared with Placebo in a Treatment Strategy for Early Rebleeding in Cirrhosis. A Double Blind, Randomized Pragmatic Trial." Hepatology 28 (1998): 1206-1214.

Garcia-Tsao, G. , and J. Bosch. "Management of Varices and Variceal Hemorrhage in Cirrhosis." New England Journal of Medicine 362 (2010): 823-832.

Grace, N. D. "Diagnosis and Treatment of Gastrointestinal Bleeding Secondary to Portal Hypertension. American College of Gastroenterology Practice Parameters Committee." The American journal of gastroenterology 92 (1997): 1081-1091.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

Zuberi, B. F. , and Q. Baloch. "Comparison of Endoscopic Variceal Sclerotherapy Alone and in Combination with Octreotide in Controlling Acute Variceal Hemorrhage and Early Rebleeding in Patients with Low-Risk Cirrhosis." The American journal of gastroenterology 95 (2000): 768-771.

Source: Medical Disability Advisor