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.

Hernia, Hiatal


Related Terms

  • Diaphragmatic Hernia
  • Hiatus Hernia
  • Mixed Hernia
  • Paraesophageal Hernia
  • Sliding Hernia
  • Type I Hernia
  • Type II Hernia
  • Type III Hernia
  • Type IV Hernia

Differential Diagnosis

Specialists

  • Gastroenterologist
  • General Surgeon

Comorbid Conditions

Factors Influencing Duration

Factors that may influence the length of disability include the type and severity of the hernia, the surgical procedure used to fix the hernia, the presence and nature of complications, and the individual's age, health status, and job requirements. The length of disability may be significantly prolonged if the hernia recurs.

Medical Codes

ICD-9-CM:
551.3 - Diaphragmatic Hernia with Gangrene; Hernia: Hiatal (Esophageal) (Sliding) Specified and Gangrenous, Paraesophageal Specified as Gangrenous; Thoracic Stomach Specified as Gangrenous
552.3 - Diaphragmatic Hernia with Obstruction
553.3 - Hernia, Hiatal

Overview

© Reed Group
A hiatal hernia is the protrusion (prolapse) of a portion of the stomach through the junction between the diaphragm and the esophagus (diaphragmatic esophageal hiatus). The diaphragm is a sheet of muscle and tendons that separates the chest and abdominal cavities and keeps the contents of those cavities separated. The hiatus, where the esophagus passes through the diaphragm, is a potential weak spot in the diaphragm. A hiatal hernia occurs when the stomach protrudes (herniates) into the chest cavity through the hiatus as a result of increased intra-abdominal pressure. Any repetitive action that increases pressure in the abdominal cavity, including chronic coughing, prolonged vomiting, straining during bowel movements, and sudden exertion, may result in hiatal hernia.

Hiatal hernias are common and in most cases go unnoticed. Over half of individuals who develop hiatal hernia will remain symptom-free. However, when the condition coexists with gastroesophageal reflux disease (GERD), in which stomach acid backflows into the esophagus, the condition may become exaggerated and can progress to acute and sometimes life-threatening conditions such as gastric volvulus or strangulation. Individuals with GERD may have more pronounced symptoms from hiatal hernia than those without GERD because the hiatal hernia traps the fluids of gastric reflux and increases the period of contact between the stomach acid and the esophagus.

Generally, there are two types of hiatal hernia: sliding (type I) and paraesophageal or rolling (type II). A mixed hiatal hernia (type III) combines the two types. Sliding hiatal hernias occur when the place where the esophagus joins the stomach (gastroesophageal junction), which normally is situated below the diaphragm, slides into the chest cavity. A sliding hiatal hernia is more likely to be associated with GERD. Paraesophageal hiatal hernia occurs when the gastroesophageal junction remains in place, but a portion of the stomach herniates into the chest cavity. Occasionally, an individual may present with a mixed hiatal hernia, which occurs when almost all of the stomach herniates into the chest cavity. In this case, the gastroesophageal junction may lie either above or below the diaphragm. If a small portion of the small intestine also protrudes through the diaphragm along with the stomach, the hernia is referred to as a type IV hernia.

Approximately 99% percent of hiatal hernias are sliding, and 1% is paraesophageal; the other types are very rare (Quereshi).

Incidence and Prevalence: Hiatal hernia occurs primarily in developed countries that consume a Western diet low in fiber (Quereshi).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk for hiatal hernia is higher in individuals over age 40, and frequency generally increases with age, ranging from 10% in those younger than 40, to 70% in those over age 70 (Quereshi). Pregnancy, obesity, or consuming insufficient fiber (leading to constipation and straining) increases an individual's risk of developing a hiatal hernia. Women are more likely than men to develop paraesophageal hiatal hernias but only slightly more likely than men to develop sliding hernias. This is believed to be due to the increased intra-abdominal pressure of pregnancy. Race is not a risk factor in hiatal hernia.

Source: Medical Disability Advisor



Diagnosis

History: Most hiatal hernias cause no symptoms; they are discovered incidentally from the results of chest x-ray or computed tomography (CT) scans taken for unrelated reasons. Individuals may report heartburn or chest pain that is more pronounced when they are lying flat, indicative more of coexisting GERD and hiatal hernia than of hiatal hernia alone. Initial symptoms of hiatal hernia, however, may be similar to reflux symptoms. Heartburn may wake the individual at night, or it may be more noticeable in the morning. Heartburn often is reported 30 to 60 minutes after eating or drinking. Individuals may report the sensation that food is sticking in the chest or upper abdomen, and they may complain of food or stomach acid regurgitating into the mouth.

Physical exam: A physical exam is not helpful for this diagnosis. Risk factors such as pregnancy, obesity, and excess abdominal fluid (ascites) may increase suspicion of hiatal hernia and encourage appropriate tests.

Tests: The diagnostic tool of choice for hiatal hernia is an upper gastrointestinal (GI) barium series. In this procedure, the esophagus and stomach are visualized by making a series of x-rays after the individual swallows a radiopaque dye (barium swallow). Movement of the barium is followed into the stomach and intestine. Other methods may further define the condition: A flexible fiberoptic instrument with a microscope at its tip can be inserted into the esophagus (esophagoscopy) for direct visualization and diagnosis. A tissue sample (biopsy) of the esophagus may be taken during esophagoscopy for microscopic analysis. A motility study may determine if the esophagus and stomach are contracting properly. A complete blood count (CBC) may be done to evaluate for anemia. Other tests may include measurement of pressure in the esophagus (esophageal manometry), measurement of stomach acid production (pH telemetry), determination of how well the esophagus is functioning (esophageal clearance studies), and an assessment of heart function (electrocardiogram [ECG]).

Source: Medical Disability Advisor



Treatment

In uncomplicated cases, lifestyle changes (e.g., weight loss, increasing dietary fiber, avoiding actions that increase intra-abdominal pressure) and acid-neutralizing medication may alleviate the symptoms associated with hiatal hernia. Initial treatment may include administering antacids and drugs (e.g., H2 histamine receptor blockers, proton pump inhibitors [PPIs]) that decrease stomach acid secretion. Medical therapy also may include drugs to increase esophageal and gastric motility. Elevating the head of the bed; avoiding large, late evening meals; avoiding highly seasoned foods, fatty foods, citrus juices, coffee, smoking, and alcohol; wearing loose-fitting clothing; and eating small, frequent meals, also may be beneficial in relieving symptoms.

Surgical intervention usually is limited to treating more serious complications, such as volvulus, strangulation, or pulmonary complications, but may also be done prophylactically to prevent such complications or in situations in which aggressive medical treatment with PPIs has failed to relieve GERD symptoms. If the individual requires surgery, the surgeon wraps the gastric fundus around the gastroesophageal junction (Nissen or Belsey fundoplication) and returns the stomach to the abdomen (mobilization) and sutures it in place. Surgery for paraesophageal hernia pulls the hernial sac back into the abdomen and reduces the size of the esophageal hiatus; sometimes the stomach is tacked down to prevent future migration. In many cases the surgeon can view the field through a fiberoptic camera and accomplish these procedures through small laparoscopic incisions in the abdomen. If this is not possible, a more generous surgical field is then provided through an open incision in the chest wall (thoracotomy) or the abdomen (laparotomy). Recovery time with an open procedure is longer, and risk of complications (e.g., bleeding, infection) is higher.

Source: Medical Disability Advisor



Prognosis

Most individuals with a sliding hiatal hernia can expect relief of symptoms by using antacids and drugs that decrease stomach acid secretion and by making appropriate lifestyle modifications. Most individuals treated surgically find they are relieved of symptoms. However, following surgery, some symptoms of hiatal hernia (i.e., heartburn, chest pain, a feeling of food sticking in the chest or upper abdomen) may continue to occur in some individuals, and a small number of individuals will have recurrence of the condition. Strangulation of hiatal hernia occurs rarely, and only with paraesophageal hernia. Individuals with paraesophageal hernia may develop strangulation of the hernia and gastric volvulus; if this leads to perforation, mortality is high.

Source: Medical Disability Advisor



Rehabilitation

Following abdominal surgery, intermittent positive pressure breathing exercises may be necessary to prevent pulmonary complications. Also, certain exercises may be performed to reduce postoperative pain and speed recovery, including progressive relaxation and deep-breathing techniques. These exercises may be performed several times per day until pain from inhalation/exhalation tapers off. Ankle flexes, knee bends, and crossed-leg muscle contractions (all while lying on the back) will help to increase circulation and make walking easier. These are especially valuable during the first 48 hours after surgery and should be performed 3 to 5 times per day during this time. Individuals may continue with these exercises for 4 to 6 weeks or until recovery from surgery is complete and pain is no longer noticeable while walking or breathing.

Source: Medical Disability Advisor



Complications

Possible complications of hiatal hernia may include backflow of stomach acid into the esophagus (esophageal reflux), which can cause the esophagus to bleed and erode (ulcerate). Occasionally these symptoms may lead to cellular changes that predispose toward esophageal cancer (Barrett's esophagus). Stomach contents may be aspirated into the lungs while asleep, with consequent respiratory infection (aspiration pneumonia) and/or symptoms of asthma. Bleeding from the lower esophagus or inner lining of the stomach also may result in anemia; massive bleeding rarely occurs. Excessive gas (flatulence) and swelling of the upper abdomen (epigastric distention) may occur. An abnormal narrowing (stricture) of the esophagus or stomach is another potential complication. Occasionally, the prolapsed stomach may twist on itself (organo-axial gastric volvulus), producing pain, nausea, vomiting, and tissue death (necrosis). This condition is potentially a life-threatening situation and requires immediate surgical intervention.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Restrictions on lifting, climbing, and strenuous physical activity will be necessary following surgical repair of hiatal hernia. As mentioned, recurrence of hiatal hernia is not uncommon, and permanent work restrictions and accommodations may include avoidance of bending, lifting, and abdominal straining. Also, the individual should not be subjected to any sort of abdominal constriction and should wear loose clothing. The individual will benefit from eating small, frequent meals (rather than a large, single meal) while at work. If pain medication is still needed upon return to work, company policy on medication use should be reviewed to determine if medication usage 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:

  • Did individual report heavy coughing, or straining during bowel movements?
  • Is individual pregnant or obese?
  • Did individual report heartburn or chest pain that is worse when lying flat?
  • Did heartburn sometimes wake the individual at night? Is it more noticeable in the morning?
  • Did individual have the sensation that food is sticking in the chest or upper abdomen?
  • Did individual complain of food or stomach acid regurgitation into the mouth?
  • Did individual have pre-existing, untreated GERD?
  • Did individual have a barium swallow and esophagoscopy?
  • Was a biopsy of the esophagus done? Does biopsy show Barrett's esophagus?
  • Was a motility study done?
  • Did individual have a CBC? Was there evidence of anemia?
  • Did individual also have esophageal manometry, pH telemetry, esophageal clearance studies, and an ECG?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Were antacids and drugs that decrease stomach acid secretion prescribed? Were they effective?
  • Does individual elevate the head of the bed?
  • Does individual avoid large late evening meals, highly seasoned foods, citrus juices, and alcohol?
  • Does individual wear loose-fitting clothing?
  • Does individual eat small, frequent meals?
  • Has individual increased fiber in the diet?
  • Was surgery necessary? What type of surgery was performed?

Regarding prognosis:

  • If surgery was performed, were there any complications?
  • Is individual's employer able to accommodate any necessary restrictions?
  • Does individual have any conditions that could affect the ability to recover?
  • Does individual have esophageal reflux or pre-existing GERD? Is it being treated successfully?
  • Does individual have a respiratory infection caused by aspirating stomach acid or food particles while asleep?
  • Does individual have flatulence and epigastric distention?
  • Have complications occurred such as stricture, volvulus, strangulation, or perforation that required immediate surgery?
  • Has individual made recommended lifestyle changes such as losing weight, increasing dietary fiber, and avoiding actions that increase intra-abdominal pressure?
  • Is individual older than age 40?
  • Would individual benefit from nutritional counseling and a weight loss program?

Source: Medical Disability Advisor



References

Cited

Qureshi, Waqar A. "Hiatal Hernia." eMedicine. Eds. Vivek Gumaste, et al. 24 Aug. 2009. Medscape. 21 Nov. 2009 <http://emedicine.medcape.com/article/178393-overview>.

Source: Medical Disability Advisor






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