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.

Gastrointestinal Hemorrhage


Related Terms

  • Gastrointestinal Bleeding
  • Lower Intestinal Bleeding
  • Upper Gastrointestinal Bleeding

Differential Diagnosis

Specialists

  • Gastroenterologist
  • Internal Medicine Physician

Comorbid Conditions

Factors Influencing Duration

The age of the individual, the recurrence of bleeding, persistent anemia, and the individual's response to treatment may influence the length of disability. Duration of disability will depend upon the underlying cause and severity of the condition. In some cases, disability may be permanent.

Medical Codes

ICD-9-CM:
569.3 - Hemorrhage of Rectum and Anus
578.9 - Hemorrhage of Gastrointestinal Tract, Unspecified

Overview

Gastrointestinal hemorrhage is bleeding within the gastrointestinal (GI) tract.

The GI system is divided into the upper GI tract, which includes the esophagus, stomach and the first part of the small intestine (duodenum), and the lower GI tract, which includes the rest of the small intestine (jejunum and ileum) and the large intestine (colon). Severe bleeding occurs more often in the upper GI tract than in the lower GI tract and warrants emergency treatment.

The most frequent causes of upper GI bleeding are stomach (peptic) ulcers, gastritis, ruptured esophageal veins (varices), inflammation of the esophagus (erosive esophagitis), or a Mallory-Weiss tear, which is a tear in the esophageal or stomach wall, often caused by vomiting. Lower GI hemorrhage occurs most often in the large intestine (colon) and may rarely be caused by lesions in the small intestine. Frequently, the cause for lower GI bleeding is diverticulosis. Diverticula are pouches on the colon, much like the appendix, that push through the lining of the colon and into the muscle tissue. When diverticula become inflamed (diverticulitis), they can cause hemorrhage. Other causes for lower GI bleeding include inflammation of the colon because of infection (infectious colitis), hemorrhoids and fissures, inflammatory bowel disease (IBD), angiodysplasia (a malformation in the blood vessels in the wall of the gastrointestinal tract), Crohn's disease (regional enteritis), ulcerations on the colon (ulcerative colitis), polyps, and cancer.

Incidence and Prevalence: In 2009 there were over 700,000 cases of hospitalizations from GI complications about equally distributed between men and women. Hospitalizations for upper GI bleeding have been steadily decreasing since a peak in 2004. Among hospitalizations for GI bleeding, bleeding in the upper, lower and undefined regions accounts for about 40%, 25%, and 35%, respectively. UGI bleeding accounts for about 92% of UGI complications and over half of these cases are due to peptic ulcer disease (Laine).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk factors for upper GI bleeding include considerable use of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) (De Berardis), which can cause erosion of the protective lining (mucosa) in the GI tract, and cigarettes and alcohol consumption.

The risk of hospitalization for lower GI bleeding increases dramatically with age. A ninety year old is 200 times as likely to be hospitalized for lower GI bleeding compared to a thirty year old. Diverticulosis accounts for about 50% of all lower GI bleeding, followed by ischemic colitis and anorectal lesions (Srate).

Source: Medical Disability Advisor



Diagnosis

History: The individual may complain of vomiting bright red blood (hematemesis), but if the bleeding has slowed and the blood has darkened (partially digested), complaints of vomitus that looks like coffee grounds may be noted. Complaints of tarry, black stools (melena) or of bright red blood in the stool (hematochezia) may be made. The individual might complain of stomach pain, lack of appetite, weight loss, fatigue, weakness, dizziness, or chest pain. Bright red blood from the rectum usually is due to hemorrhoids.

Physical exam: The individual may appear to be pale (pallor) and/or weak, and the extremities may be moist and cool. Blood pressure and pulse measurements may reflect changes when the individual moves from a lying or sitting position to a standing position (orthostatic measurements). Orthostatic changes are evident when a change in the pulse rate of greater than 10 beats/minute or a drop in blood pressure of 10 points (mmHg) occurs. Listening to the abdomen with a stethoscope (auscultation) may reveal overactive sounds in the bowel (hyperactive bowel sounds) if blood is present. Insertion of a gloved finger into the anus and up into the rectum (digital rectal exam) is done to check for masses, hemorrhoids, or ulcerations.

Tests: Blood tests may include a complete blood count (CBC) to monitor hemoglobin and hematocrit for anemia and to monitor clotting (coagulation) parameters, such as platelet count and prothrombin time. A tagged red blood cell scan may be performed. The blood may be typed and cross-matched in the event that the individual requires a blood transfusion. Blood tests to determine liver function abnormalities and chemical testing of the stool for occult blood should be done.

Imaging tests for the upper GI tract involve insertion of a viewing tube (endoscope) through the mouth, into the esophagus, and down into the stomach and upper duodenum (panendoscopy) to determine the source of bleeding. During the procedure, the physician can insert various instruments through the endoscope to stop bleeding or to take a tissue sample for exam under a microscope (biopsy). If panendoscopy is unavailable, upper GI barium x-rays or other imaging tests (abdominal CT scan, abdominal MRI, or angiography) may be performed. A capsule endoscopy, a camera pill that can be swallowed to view the small intestine, may be administered.

Lower GI tract diagnostic tests also require that various endoscopic procedures be performed. The anus (anoscopy), the lower portion of the large intestine (sigmoid colon) above the rectum (sigmoidoscopy), and the entire large intestine, or colon (colonoscopy), can be viewed. As with endoscopic procedures for upper GI bleeding, bleeding may be stopped and biopsies may be taken through these viewing scopes.

Source: Medical Disability Advisor



Treatment

Any bright red blood in vomitus or stool and any black, tarry stools are considered medical emergencies until otherwise proven. The individual is hospitalized and placed on intravenous (IV) fluids. Blood replacement is given, if needed. A tube, attached to a pump, is inserted through the nose into the stomach (nasogastric or NG tube) so that blood can be removed and the GI tract can rest; nothing is given to the individual by mouth. If endoscopic exams of the upper or lower GI tract reveal bleeding, the bleeding may be stopped by applying electrical charges (bipolar electrocoagulation) or lasers to the bleeding areas (cauterization). Chronic, bleeding internal hemorrhoids may be treated medically or surgically.

Surgical correction may be necessary in some cases of gastrointestinal bleeding. Endoscopic banding, sclerotherapy, or a transjugular intrahepatic portosystemic shunt (TIPS) procedure may be performed in cases of severe esophageal variceal bleeding. Severe bleeding from the stomach may require surgical removal of part of the stomach (gastric resection) or cutting part of the vagus nerve (vagotomy). Colonoscopic polypectomy or laparotomy may be performed to remove other lower GI lesions such as cancer or polyps.

Source: Medical Disability Advisor



Prognosis

In about 75% of cases, GI bleeding stops on its own (Strate). Those who must undergo surgical correction may have very good outcomes, but the prognosis depends on the underlying cause for the bleeding and the severity of the blood loss. Individuals with esophageal varices or peptic ulcer in which a hemorrhage cannot be stopped may die.

Source: Medical Disability Advisor



Complications

Complications of GI hemorrhage include anemia, chemical and fluid imbalances in the body, recurrent bleeding, or significant loss of blood leading to shock (hemorrhagic shock).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

There may be activity or lifting restrictions if a minimally invasive or invasive procedure, or surgery, is performed. The individual may benefit from avoiding stressful situations. Individuals will need a gradual increase in normal activities to rebuild stamina and strength.

"For more information, please refer to "Work Ability and Return to Work," pages 364-365.

Tolerance: If an underlying illness has caused a prolonged convalescence, the patient may be deconditioned and require physical therapy to regain activity.

Source: Medical Disability Advisor



Maximum Medical Improvement

The underlying cause may dictate a different time to MMI status, but absent surgical intervention, a patient would be at MMI in 1 month.

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 stomach (peptic) ulcers or inflammation of the esophagus (erosive esophagitis)?
  • Does individual take considerable amounts of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs)?
  • How much alcohol does the individual consume and how often?
  • Does individual have a history of diverticulosis, colitis, hemorrhoids, inflammatory bowel disease (IBD), or cancer?
  • Does individual complain of vomiting bright red blood (hematemesis) or of vomitus that looks like coffee grounds?
  • Has individual noticed tarry, black stools (melena) or bright red blood in the stool (hematochezia)?
  • Does individual report stomach pain, lack of appetite, weight loss, fatigue, weakness, dizziness, or chest pain?
  • Was a complete blood count (CBC) done to monitor hemoglobin and hematocrit for anemia?
  • Were clotting (coagulation) parameters measured?
  • Were blood tests done to determine liver function abnormalities?
  • Was stool tested for the presence of blood?
  • Were imaging tests for the upper GI tract done, including upper GI x-rays or insertion of a viewing tube through the mouth, into the esophagus, and down into the stomach and duodenum (panendoscopy)?
  • Was the lower GI tract viewed either by anoscopy, sigmoidoscopy, or colonoscopy?
  • Was diagnosis of upper or lower GI tract hemorrhage confirmed?

Regarding treatment:

  • Did individual require emergent medical care for bright, red blood in vomitus or stool, or for black, tarry stools?
  • Did individual require intravenous (IV) fluid and blood replacement?
  • Was a nasogastric (NG) tube placed for blood removal and for the GI tract to rest?
  • If endoscopic exams of the upper or lower GI tract revealed bleeding, was the bleeding stopped with electrical charges (bipolar electrocoagulation) or lasers (cauterization)?
  • Did severe bleeding require surgical correction, such as removing part of the stomach (gastric resection) or cutting part of the vagus nerve (vagotomy)?
  • If surgery was done, did it stop the bleeding completely?
  • Has individual been instructed to refrain from drinking alcohol or caffeine and smoking cigarettes?

Regarding prognosis:

  • Did individual experience upper or lower GI bleeding?
  • Did bleeding stop on its own, or was intervention required?
  • How severe was blood loss?
  • If severe, how will this affect the daily activities of individual and for how long?
  • Was this an initial bleeding episode, or a recurrence?
  • Is individual compliant with refraining from alcohol, caffeine, and smoking?
  • Does individual have an underlying condition that might prolong recovery?
  • What is the condition, and how can it be treated?
  • If surgery was required, did any postsurgical complications occur? If so, what were they, and what is their expected outcome with treatment?
  • Has individual developed anemia or chemical and fluid imbalances?
  • If so, how will they be treated, and what is their expected outcome with treatment?

Source: Medical Disability Advisor



References

Cited

De Berardis, G. , et al. "Association of Aspirin Use with Major Bleeding in Patients with and without Diabetes." JAMA 307 (2012): 2286-2294.

Laine, L. , et al. "Trends for Incidence of Hospitalization and Death Due to Gi Complications in the United States from 2001 to 2009." The American journal of gastroenterology 107 (2012): 1190-1196.

Strate, L. L. "Lower Gi Bleeding: Epidemiology and Diagnosis." Gastroenterology Clinics of North America 34 (2005): 643-664.

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






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