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.

Gastroesophageal Reflux


Related Terms

  • Esophageal Reflux
  • Esophagitis
  • Gastroesophageal Reflux Disease (GERD)
  • GERD
  • Heartburn

Differential Diagnosis

Specialists

  • Gastroenterologist
  • General Surgeon
  • Internal Medicine Physician

Comorbid Conditions

  • Alcohol use
  • Obesity
  • Smoking

Factors Influencing Duration

Length of disability may be influenced by the severity of symptoms, type of treatment (phase I, II, or III), compliance with and response to treatment, and the presence and severity of reflux complications. If the treatment is surgical, length of disability also depends on the type of surgery and any surgical complications.

Medical Codes

ICD-9-CM:
530.11 - Esophagitis, Reflux
530.81 - Esophageal Reflux

Overview

© Reed Group
Gastroesophageal reflux refers to a backflow (reflux) of stomach contents into the esophagus. While some degree of gastroesophageal reflux is normal and occurs in many individuals after consuming a meal, gastroesophageal reflux disease (GERD) involves reflux of an abnormal amount of gastric juice into the esophagus with signs and symptoms of esophageal irritation.

The esophagus is the muscular tube that carries food from the throat to the stomach. Food is moved along the esophagus by waves of contraction and relaxation of its muscular walls (peristalsis). The part of the esophagus closest to the stomach is surrounded by a circular muscle capable of opening and closing (lower esophageal sphincter [LES]). During peristalsis, the LES relaxes, allowing food to enter the stomach. In the absence of food intake, this sphincter is closed, preventing reflux of stomach contents into the esophagus. However, a drop in pressure in the lower esophagus or a weakening of the sphincter muscle can permit a reflux of powerful stomach acid into the esophagus. While the lining of the stomach protects it from the effects of its own acid, the esophagus lacks this protective lining. A backflow of the highly acidic stomach contents into the esophagus can cause heartburn, inflammation (esophagitis), and damage to the esophagus. The degree of inflammation depends on the acidity of the stomach contents and the amount of stomach acid refluxed into the esophagus.

Certain foods or circumstances increase the risk of reflux by reducing normal pressure of the sphincter or increasing abdominal pressure. Exercising or bending over after a large meal can change pressure on the sphincter and allow stomach contents to reflux into the esophagus. When an individual is lying down, gravity contributes to reflux; this is particularly evident if lying down soon after a large meal. Consumption of certain types of foods, drinks, and drugs, as well as smoking, can result in reflux. Reflux also can be caused by anything that increases abdominal pressure such as clothing or belts worn too tightly around the waist. Reflux may occur in association with pregnancy or obesity because abdominal pressure is increased.

Reflux also is associated with hiatal hernia. The esophagus enters the stomach just after passing through a band of muscle called the diaphragm. In a hiatal hernia, the opening (hiatus) in the diaphragm through which the esophagus passes is enlarged. This allows the lower esophagus and upper part of the stomach that normally stay beneath the diaphragm to slide through the hiatus and move above the diaphragm into the chest cavity. This makes it difficult for the sphincter to work correctly, partially because the angle between the esophagus and stomach (gastroesophageal angle) is changed.

Based on geographic and ethnic distributions of GERD, it is speculated that gastritis secondary to Helicobacter pylori infection may protect against GERD. However, the relationship between H. pylori infection and gastroesophageal reflux disease (GERD) is not clearly established.

Incidence and Prevalence: Heartburn symptoms affect about 10% to 20% of the population in the US and tend to remain a problem for such individuals for many years (Dent). The prevalence of heartburn or acid regurgitation in the US is roughly double the rate found in Europe and 3 or 4 times the rate in Asia (Dent).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals who are overweight, pregnant, smoke, use alcohol, or have a genetic propensity or family history of reflux have an increased risk of gastroesophageal reflux (Dent; Mohammed). Clinical risk for developing GERD is higher in individuals with functional or mechanical defects of the LES. A high body mass index (BMI) is considered a risk factor for developing GERD, and the disease and its complications are more prevalent among obese and morbidly obese individuals (Dent ).

GERD occurs equally in men and women (Dent). White males have increased risk for Barrett's esophagus, a precancerous condition. Because GERD in white males progresses to Barrett's esophagitis 4 times more frequently than in females (Chak), white males have an increased likelihood of developing esophageal adenocarcinoma, a condition that may develop from chronic GERD. The relationship between age and GERD is unclear although it appears that GERD, which occurs in people of all ages, increases in prevalence until the 5th or 6th decade of life: after that the prevalence appears to decrease with increasing age (Dent).

Source: Medical Disability Advisor



Diagnosis

History: Most individuals report a burning sensation (heartburn) in the lower chest, usually behind the breastbone (sternum). Pain may also be present and may range from mild to so severe that it mimics a heart attack (myocardial infarction). Gastroesophageal reflux, however, is not related to any heart conditions.

Heartburn typically occurs 30 to 60 minutes after eating and often is precipitated by other common symptoms of reflux. These include a reflex increase in salivation (water brash) and backward flow of stomach contents into the mouth (regurgitation). Inhalation (aspiration) of regurgitated material can occur, especially during sleep; this may result in respiratory symptoms such as hoarseness, wheezing, cough, and difficulty breathing. Difficulty swallowing (dysphagia) and chest pain are often symptoms of complicated GERD. Painful swallowing (odynophagia) may indicate esophageal inflammation or an esophageal ulcer.

Physical exam: Diagnosis is usually suspected from the history with little contribution from physical examination; however, in some individuals it may be necessary to rule out a cardiac source of pain (e.g., myocardial infarction, angina pectoris) and other gastrointestinal disease.

Tests: The healthcare provider may order an upper gastrointestinal barium x-ray (esophagogastroduodenal series or upper GI series) and/or a direct examination of the esophagus (esophagoscopy) through a flexible fiberoptic tube (endoscope). A capsule endoscopy is another option. These procedures can detect ulcers, Barrett's esophagus, and narrowing of the esophagus (esophageal stricture). Regardless of x-ray or endoscopic findings, proof that the symptoms are caused by acid reflux is best obtained through a tissue sample (biopsy) and microscopic examination.

When symptoms are not typical, special studies may be required to make the diagnosis. The simplest of these tests is the Bernstein acid perfusion test. In this test, a specific concentration of hydrochloric acid is instilled into the esophagus. If the individual's pain is reproduced by this procedure and relieved by instillation of saline solution, it is an indication that acid reflux is the cause of the pain. The test considered most diagnostic is the ambulatory acidity (pH) monitoring. By continuously monitoring the pH of the esophagus for up to 24 hours, the individual's daily pattern of reflux and its relationship to symptom occurrence can be documented.

Pressure measurement (esophageal manometry) at the lower esophageal sphincter can indicate poor sphincter strength and abnormal functioning.

Radioisotope scans sometimes are done to demonstrate reflux. A reflux scan is less sensitive than 24-hour pH monitoring; however, it can help document aspiration of regurgitated material.

Source: Medical Disability Advisor



Treatment

Treatment of symptomatic reflux may be considered in several phases. Phase I consists of lifestyle modification measures, phase II is medical treatment, and phase III is surgical intervention.

Phase I measures include strategies that mechanically decrease abdominal pressure and that modify intake of known aggravating substances. Weight loss may make a difference for overweight or morbidly obese people. Tight clothing and belts are avoided. Meals are generally small and frequent. Reclining is avoided for at least 2 hours after meals. Gravity may help relieve symptoms if the head of the bed is raised or more than one pillow is used when reclining. The individual is advised to avoid substances that increase symptoms, such as alcohol, tobacco, caffeinated drinks, acidic drinks (e.g., citrus or tomato juice), acidic foods, fats, chocolates, and peppermint.

Medications are reviewed and possibly discontinued or changed since certain medications (e.g., anticholinergic drugs, calcium channel blockers) can decrease LES tone. Others, such as potassium supplements and certain antibiotics, may irritate the esophagus. The acid-neutralizing effect of antacids also may be helpful when taken after meals and at bedtime. However, this relief is only short-term.

While uncomplicated reflux usually responds well to phase I therapy, if the above measures fail to control symptoms and there is progression of the disease and development of complications, generally phase II treatment is required. In phase II treatment inhibitors of gastric acid secretion such as proton pump inhibitors (PPIs) (e.g., omeprazole) that directly block the secretion of acid by the stomach, or histamine (H2) antagonists (e.g., cimetidine), are introduced. Although the medication often produces complete healing in 4 to 8 weeks, most individuals have recurrence of symptoms after the drug is discontinued. Gastroesophageal reflux symptoms tend to be chronic whether or not there is esophagitis; thus, a commonly used management strategy is provide treatment indefinitely with PPIs or histamine (H2) antagonists as needed for controlling symptoms, with monitoring for side effects. Rarely, PPIs or histamine (H2) antagonists may lead to bone loss, so it is advisable to prescribe a calcium supplement to reduce these risks. If the response to PPIs or histamine (H2) antagonists is incomplete, cholinergic drugs or other motility promoting (prokinetic) agents may be added. These medications increase esophageal and gastric movement, increase LES tone, and promote gastric emptying. Medication to protect the mucous lining also may be tried.

Phase III treatment, consisting of antireflux surgery, is indicated when symptoms persist or recur despite nonsurgical (conservative) phases I and II treatment. A weakened esophageal sphincter can be surgically strengthened. A hiatal hernia can be reduced by surgically returning the stomach and esophagus to their normal position in the abdominal cavity. The hiatal opening is then secured with sutures. Another procedure called Nissen fundoplication creates a high-pressure area in the lower esophagus by surgically wrapping the upper left portion (fundus) of the stomach around the distal esophagus, preventing reflux. The procedure can be performed laparoscopically.

Source: Medical Disability Advisor



Prognosis

The clinical course of gastroesophageal reflux varies. While some symptoms resolve, others may be resistant to therapy. Most individuals with mild disease will continue to experience symptoms of varying degrees and frequency. About 25% of GERD patients will progress to erosive disease despite treatment (Pace). About 10% progress to Barrett's esophagus (stage IV esophagitis with metaplasia) and eventual esophageal adenocarcinoma (Dent). When symptoms are severe or resistant to treatment, surgery may be required (Anvari). About 80% to 95% of patients who undergo laparoscopic antireflux surgery are symptom free at 5 years after surgery (Anvari). A small but significant portion of patients experience surgery failure. Those patients are more likely to have had no response to acid reducing medications, atypical symptoms and are morbidly obese (Morganthal 2007).

Source: Medical Disability Advisor



Complications

Complications include vomiting, hoarseness, chronic cough, recurrent disease, and choking sensations. A small percentage of the individuals with severe reflux esophagitis develop esophageal stricture. Barrett's esophagus is a precancerous condition involving changes in the esophageal lining due to damage from persistent acid reflux; it may progress to cancer (esophageal adenocarcinoma).

Aspiration of stomach contents into the lungs may cause damage resulting in pneumonia. Asthma and GERD often occur together. Chronic microaspiration of gastric contents has a potential role in the etiology and natural history of idiopathic pulmonary fibrosis. Complications also may include ear infection (otitis media) and tooth decay from acid exposure. The vocal cords may be affected, resulting in laryngitis or cancer.

Complications also may include odynophagia and noncardiac chest pain that may indicate the development of ulcers. Anticholinergic drugs commonly used to treat asthma increase the tendency of the lower esophageal sphincter to leak and may lengthen disability.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Restrictions or accommodations normally are not necessary.

For more information on risk, capacity, and tolerance, refer to "Work Ability and Return to Work," pages 354-355.

Risk: No job meeting OSHA standards would contribute to caustic esophageal changes, progressive cancer, or impact esophageal webs. GERD can be brought out by large late night meals, obesity, alcohol, caffeine, cigarettes, anti-inflammatories, pain, stress and at times chocolate, peppermint, and spearmint. Jobs with heavy bending may increase symptoms and may best be avoided until symptoms are controlled with PPI. Scleroderma has been associated with exposure to silica dust, vinyl chloride and polyvinyl chloride.

Source: Medical Disability Advisor



Maximum Medical Improvement

14 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:

  • Has diagnosis of gastroesophageal reflux been confirmed?
  • Was diagnosis confirmed by upper GI series, esophagoscopy, biopsy, and/or Bernstein acid test?
  • Have conditions with similar symptoms been ruled out?
  • Have associated causes or conditions that may aggravate the condition been identified?

Regarding treatment:

  • Has individual been instructed in lifestyle and diet modifications, including losing weight, abstaining from alcohol, tobacco, caffeine, acidic and fatty foods, and wearing nonrestrictive clothing? Is individual complaint with recommended changes? What can be done to enhance compliance?
  • Have medications taken for other conditions been reviewed? Can any that may contribute to reflux be replaced or eliminated?
  • Does use of PPIs or H2 antagonists effectively control symptoms? Was necessary to add cholinergics?
  • If symptoms were severe or resistant to treatment, was surgery required?
  • Which of the following procedures was performed or is scheduled to be performed: surgical strengthening of the esophageal sphincter; correction of a hiatal hernia; or a Nissen fundoplication to create a high-pressure area in the lower esophagus?

Regarding prognosis:

  • Do symptoms persist despite medical treatment? How severe are the symptoms?
  • Would individual benefit from counseling to assist with lifestyle and dietary changes?
  • Would individual benefit from evaluation by a gastroenterologist?
  • If individual underwent surgery, was it successful? Is individual symptom free?
  • Has individual experienced any complications associated with the gastroesophageal reflux or the surgical intervention?
  • Are complications being effectively addressed in the overall treatment plan?

Source: Medical Disability Advisor



References

Cited

Anvari, M. , and C. Allen. "Surgical Outcome in Gastro-Esophageal Reflux Disease Patients with Inadequate Response to Proton Pump Inhibitors." Surgical Endoscopy 17 (2003): 1029-1035.

Chak, A. , et al. "Familial Aggregation of Barrett's Oesophagus, Oesophageal Adenocarcinoma, and Oesophagogastric Junctional Adenocarcinoma in Caucasian Adults." Gut 51 (2002): 323-217.

Dent, J. , et al. "Epidemiology of Gastro-Oesophageal Reflux Disease: A Systematic Review." Gut 54 (2005): 710-717.

Mohammed, I. , et al. "Genetic Influences in Gastro-Oesophageal Reflux Disease: A Twin Study." Gut 52 (2003): 1085-1089.

Morgenthal, C. B. , et al. "Who Will Fail Laparoscopic Nissen Fundoplication? Preoperative Prediction of Long-Term Outcomes." Surgical Endoscopy 21 (2007): 1978-1984.

Pace, F. , et al. "Outcome of Nonerosive Gastro-Esophageal Reflux Disease Patients with Pathological Acid Exposure." World journal of gastroenterology (WJG) 15 2009 5700-5705.

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.

Source: Medical Disability Advisor






Feedback
Send us comments, suggestions, corrections, or anything you would like us to hear. If you are not logged in, you must include your email address, in order for us to respond. We cannot, unfortunately, respond to every comment. If you are seeking medical advice, please contact your physician. Thank you!
Send this comment to:
Sales Customer Support Content Development
 
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is published with the understanding that the author, editors, and publisher are not engaged in rendering medical, legal, accounting or other professional service. If medical, legal, or other expert assistance is required, the service of a competent professional should be sought. We are unable to respond to requests for advice. Any Sales inquiries should include an email address or other means of communication.