Digestive System

• Author: David A. Morton III
• Pages: 609-698

5-1

Chapter 5

Digestive System

Contents

Part I - Adults

§5.00 Digestive System

§5.01 Category of Impairments, Digestive System

§5.02 Gastrointestinal Hemorrhaging From Any Cause

§5.03 (Reserved)

§5.04 (Reserved)

§5.05 Chronic Liver Disease

§5.06 Inflammatory Bowel Disease (IBD)

§5.07 Short Bowel Syndrome (SBS)

§5.08 Weight Loss

§5.09 Liver Transplantation

Part II – Children

§105.00 Digestive System

§105.01 Category of Impairments, Digestive System

§105.02 Gastrointestinal Hemorrhaging From Any Cause

§105.03 (Reserved)

§105.04 (Reserved)

§105.05 Chronic Liver Disease

§105.06 Inflammatory Bowel Disease (IBD)

§105.07 Short Bowel Syndrome (SBS)

§105.08 Growth Failure Due to Any Digestive Disorder

§105.09 Liver Transplantation

§105.10 Need for Supplemental Daily Enteral Feeding Via a Gastrostomy

Part III – Forms

§5.02 Gastrointestinal Hemorrhaging From Any Cause

§5.05 Chronic Liver Disease

§5.06 Inflammatory Bowel Disease (IBD)

§5.07 Short Bowel Syndrome (SBS)

§5.08 Weight Loss

§5.09 Liver Transplantation

Note: Form 5.03 (2006 version, Appendix 27) for esophageal obstruction and Form 5.04 (2006 version,

Appendix 28) for peptic ulcer disease may be useful in specific instances such as continuing disability

claims where prior listings still have validity.

§5.00 MEDICAL ISSUES IN SOCIAL SECURITY DISABILITY 5-2

Part I - Adults

§5.00 Digestive System

[The applicable Listing of Impairments introduces

each chapter and is typeset in Helvetica. Author

comments follow each Listing subsection and are type-

set in Times.]

SSA Listing of Impairments

A. What kinds of disorders do we consider in the

digestive system?

Disorders of the digestive system include gastrointes-

tinal hemorrhage, hepatic (liver) dysfunction, inflam-

matory bowel disease, short bowel syndrome, and

malnutrition. They may also lead to complications,

such as obstruction, or be accompanied by manifesta-

tions in other body systems.

B. What documentation do we need?

We need a record of your medical evidence,

including clinical and laboratory findings. The

documentation should include appropriate medi-

cally acceptable imaging studies and reports of

endoscopy, operations, and pathology, as appro-

priate to each listing, to document the severity

and duration of your digestive disorder. Medically

acceptable imaging includes, but is not limit-

ed to, x-ray imaging, sonography, computerized

axial tomography (CAT scan), magnetic reso-

nance imaging (MRI), and radionuclide scans.

Appropriate means that the technique used is the

proper one to support the evaluation and diagnosis

of the disorder. The findings required by these

listings must occur within the period we are con-

sidering in connection with your application or

continuing disability review.

C. How do we consider the effects of treatment?

1. Digestive disorders frequently respond to medi-

cal or surgical treatment; therefore, we generally

consider the severity and duration of these disorders

within the context of prescribed treatment.

2. We assess the effects of treatment, including

medication, therapy, surgery, or any other form of

treatment you receive, by determining if there are

improvements in the symptoms, signs, and labora-

tory findings of your digestive disorder. We also

assess any side effects of your treatment that may

further limit your functioning.

3. To assess the effects of your treatment, we may

need information about:

a. The treatment you have been prescribed (for

example, the type of medication or therapy, or your

use of parenteral (intravenous) nutrition or supple-

mental enteral nutrition via a gastrostomy);

b. The dosage, method, and frequency of

administration;

c. Your response to the treatment;

d. Any adverse effects of such treatment; and

e. The expected duration of the treatment.

4. Because the effects of treatment may be tempo-

rary or long-term, in most cases we need informa-

tion about the impact of your treatment, including its

expected duration and side effects, over a sufficient

period of time to help us assess its outcome. When

adverse effects of treatment contribute to the severity

of your impairment(s), we will consider the duration

or expected duration of the treatment when we assess

the duration of your impairment(s).

5. If you need parenteral (intravenous) nutrition or

supplemental enteral nutrition via a gastrostomy to

avoid debilitating complications of a digestive disor-

der, this treatment will not, in itself, indicate that you

are unable to do any gainful activity, except under

5.07, short bowel syndrome (see 5.00F).

6. If you have not received ongoing treatment or have

not had an ongoing relationship with the medical com-

munity despite the existence of a severe impairment(s),

we will evaluate the severity and duration of your

digestive impairment on the basis of the current medi-

cal and other evidence in your case record. If you

have not received treatment, you may not be able to

show an impairment that meets the criteria of one

SSA Pub No. 64-039 Listing of Impairments (footnotes written by author)

5-3 DIGESTIVE SYSTEM §5.00

of the digestive system listings, but your digestive

impairment may medically equal a listing or be dis-

abling based on consideration of your residual func-

tional capacity, age, education, and work experience.

D. How do we evaluate chronic liver disease?

1. General. Chronic liver disease is characterized

by liver cell necrosis, inflammation, or scarring

(fibrosis or cirrhosis), due to any cause, that persists

for more than 6 months. Chronic liver disease may

result in portal hypertension, cholestasis (suppres-

sion of bile flow), extrahepatic manifestations, or

liver cancer. (We evaluate liver cancer under 13.19.)

Significant loss of liver function may be manifested

by hemorrhage from varices or portal hypertensive

gastropathy, ascites (accumulation of fluid in the

abdominal cavity), hydrothorax (ascitic fluid in the

chest cavity), or encephalopathy. There can also be

progressive deterioration of laboratory findings that

are indicative of liver dysfunction. Liver transplan-

tation is the only definitive cure for end stage liver

disease (ESLD).

2. Examples of chronic liver disease include, but

are not limited to, chronic hepatitis, alcoholic liver

disease, non-alcoholic steatohepatitis (NASH), pri-

mary biliary cirrhosis (PBC), primary sclerosing

cholangitis (PSC), autoimmune hepatitis, hemo-

chromatosis, drug-induced liver disease, Wilson’s

disease, and serum alpha-1 antitrypsin deficiency.

Acute hepatic injury is frequently reversible, as in

viral, drug-induced, toxin-induced, alcoholic, and

ischemic hepatitis. In the absence of evidence of a

chronic impairment, episodes of acute liver disease

do not meet 5.05.

3. Manifestations of chronic liver disease.

a. Symptoms may include, but are not limited to,

pruritis (itching), fatigue, nausea, loss of appetite,

or sleep disturbances. Symptoms of chronic liver

disease may have a poor correlation with the sever-

ity of liver disease and functional ability.

b. Signs may include, but are not limited to, jaun-

dice, enlargement of the liver and spleen, ascites,

peripheral edema, and altered mental status.

c. Laboratory findings may include, but are not

limited to, increased liver enzymes, increased serum

total bilirubin, increased ammonia levels, decreased

serum albumin, and abnormal coagulation studies,

such as increased International Normalized Ratio

(INR) or decreased platelet counts. Abnormally low

serum albumin or elevated INR levels indicate loss

of synthetic liver function, with increased likelihood

of cirrhosis and associated complications. However,

other abnormal lab tests, such as liver enzymes,

serum total bilirubin, or ammonia levels, may have

a poor correlation with the severity of liver disease

and functional ability. A liver biopsy may demon-

strate the degree of liver cell necrosis, inflamma-

tion, fibrosis, and cirrhosis. If you have had a liver

biopsy, we will make every reasonable effort to

obtain the results; however, we will not purchase

a liver biopsy. Imaging studies (CAT scan, ultra-

sound, MRI) may show the size and consistency

(fatty liver, scarring) of the liver and document asci-

tes (see 5.00D6).

4. Chronic viral hepatitis infections.

a. General.

(i) Chronic viral hepatitis infections are commonly

caused by hepatitis C virus (HCV), and to a lesser

extent, hepatitis B virus (HBV). Usually, these

are slowly progressive disorders that persist over

many years during which the symptoms and signs

are typically nonspecific, intermittent, and mild

(for example, fatigue, difficulty with concentration,

or right upper quadrant pain). Laboratory find-

ings (liver enzymes, imaging studies, liver biopsy

pathology) and complications are generally similar

in HCV and HBV. The spectrum of these chronic

viral hepatitis infections ranges widely and includes

an asymptomatic state; insidious disease with mild

to moderate symptoms associated with fluctuating

liver tests; extrahepatic manifestations; cirrhosis,

both compensated and decompensated; ESLD with

the need for liver transplantation; and liver cancer.

Treatment for chronic viral hepatitis infections var-

ies considerably based on medication tolerance,

treatment response, adverse effects of treatment, and

duration of the treatment. Comorbid disorders, such

as HIV infection, may affect the clinical course of

viral hepatitis infection(s) or may alter the response

to medical treatment.

(ii) We evaluate all types of chronic viral hepatitis

infections under 5.05 or any listing in an affected

body system(s). If your impairment(s) does not

meet or medically equal a listing, we will consider

the effects of your hepatitis when we assess your

residual functional capacity.