Manual Single National Disability Rating to Colombia - Decree 917 of 1999 (Part I of II) - Chapter V

MANUAL SINGLE NATIONAL DISABILITY
(PART I OF II)

CHAPTER V
5. DIGESTIVE
5.1 General

The criterion for evaluating the gastrointestinal tract is based on the effects of the permanent injury can have on the individual's ability to perform tasks of daily life. The findings of the assessors should be compatible with the patient's physical condition and corroborated by aid diagnostic tests. The irrecoverable of these diseases are usually shown after prolonged observation and treatment. Many of these tests are difficult or impossible to repeat or perform, either because they are expensive, there are many, difficult to perform correctly, for example, Van de Rim to determine steatorrhea, or biopsies of intra-abdominal organs. This difficulty can be supplemented, if alternatives are given the following evidence:

a) Consistency, coherence and commonality between the clinical and physical examination provided objective documentation.

b) Time evolution reasonably fit.

c) Verification of documents when necessary.

d) Using interconsultores gastroenterologists and pathologists to review the clinical and pathological findings.

It should be noted that cases of digestive cancers because of its size and existence of local and regional metastases or remotely, generate a 40% deficiency. The rating of impairment due to cancer of the digestive system is in the chapter of malignant neoplasm. However, this chapter discusses those tumors that are considered radically removed without metastases at the time of the study are not attributable to pathology of neoplastic disease after careful physical examination and ancillary tests such as ultrasound, CT and radiographic studies, etc. ., to rule out as irrefutable tumor invasion. In these cases, the assessment should be based solely on the fallout from the surgery and the digestive commitment derived from the total or partial absence of an organ or segment of the digestive tract, radical gastrectomy, extended gastrectomy, colectomy, and the existence or no surgical stomata.

Digestive system disorders result in severe damage usually alters the nutrition and hence the weight of the individual, or recurrent inflammatory lesions which cause complications generate fistulas, abscesses or obstructions of the digestive tract. These complications usually respond to treatment. Otherwise, it must be shown to persist on repeated examinations and exhausted diagnostic and therapeutic resources, presumably the damage is permanent. In general, these disorders are of two types:

a. Malnutrition or weight loss due to gastrointestinal disorders. Once the primary disorder of the digestive tract, enterocolitis, chronic pancreatitis, gastrointestinal resection, stenosis or obstruction, interference with nutrition of these will be considered as set out below for each tract injury. To this end we apply the weight tables of reference values ​​scientifically validated in the country, provided that weight loss is due to primary or secondary disorders of the digestive tract, malabsorption, poor absorption or irreversible obstruction. The weight loss caused by psychiatric disorders, endocrine, etc., Shall be evaluated according to criteria set for these conditions in the relevant chapters.

b. Surgery and Surgical Referrals intestinal tract. Gastrointestinal tract surgery, including colostomy or ileostomy, are covered by these rules while not representing a damage which affects the workplace, by itself, if the individual is able to maintain adequate nutrition and functional stoma. The dumping syndrome after gastrectomy is rarely severe damage. Recurrent peptic ulcer generally responds to treatment. Are considered as those planned definitive surgical procedures to control the ulcerative process, ie, vagotomy, pyloroplasty, subtotal gastrectomy, etc. The great post-surgery abdominal hernias with loss of anterior abdominal wall surgically irreparable generate a global deficiency between 15% and 28%, and in most cases 15%. The closure of a perforated ulcer is not a definitive surgical treatment. In this chapter, the deficiency in the digestive system relate to:

1. Mouth, esophagus, stomach, first portion of the duodenum, small intestine and pancreas.

2. Colon and rectum.

3. Anal canal.

4. Ostomy surgery.

5. Liver and bile ducts.

6. Overweight.

7. Other diseases of the abdominal wall.

For purposes of evaluation and according to the clinical picture, each of these groups is divided into several classes according to the percentage of impairment of the whole person.

5.2 Mouth, esophagus, stomach, first portion of the duodenum, small bowel and pancreas.

Boca 5.2.1

TABLE NO. 5.1: CRITERIA FOR THE GLOBAL ASSESSMENT OF DEFICIENCY OF MOUTH

Description of criteria Global Deficit (%)

a) traumatic loss of teeth. 1 to 3

b) malunions malocclusion, deformity, partial or total loss of the jaw. 5 to 8

c) Loss of vault 10 to 15

d) Disorders of mastication and jaw injuries. Temporomandibular joint. 1 to 5

e) partial amputation of the tongue 10

f) Total amputation of the tongue 20

5.2.2 EsophagusTABLE NO.NO. 5.2: CRITERIA FOR THE ASSESSMENT OF GLOBAL GAP ESOPHAGEAL

Class Description of criteria Global Deficit (%)

I · have symptoms or signs of esophageal disease. • There are anatomical changes but do not require ongoing treatment and keeps the weight. 1.0-4.9

II · This group includes individuals with signs and symptoms of organic disease of the esophagus in addition to anatomical alterations. • The control of nuisance requires medication and diet. • The weight loss does not exceed the normal range. 5.0-14.9

III · in this class are included those patients with signs, symptoms, and anatomic abnormalities of the esophagus. • The diet and drugs do not control the symptoms and signs. There is general commitment to a moderate weight loss due to esophageal disorders. 15-24.9

IV · It marked symptoms and disorders of the esophagus. · The symptoms and signs are not controlled with treatment and weight loss is a severe range, but stable due to esophageal problems. 25-37.5

5.2.3 first portion of the stomach and duodenum

When the functions of the stomach and first portion of the duodenum are disrupted, it causes impairment of the person. Symptoms and signs include nausea, vomiting, pain, bleeding, obstruction, diarrhea, malabsorption and weight loss. Nutritional deficiencies can cause hematological and neurological manifestations are evaluated in the chapter on these organ systems, usually reversible with proper treatment. There are symptoms that are often permanent and difficult to correct, such as the early dumping, dumping late chronic diarrhea and weight loss of up to 20% of ideal.

TABLE NO. 5.3: CRITERIA FOR THE GLOBAL ASSESSMENT OF DEFICIENCY OF THE STOMACH AND FIRST PORTION OF DUODENUM

Class Description of criteria Global Deficit (%)

• In this category I have symptoms and signs without necessarily having an anatomical alteration. 1.0-4.9

II · This includes patients with symptoms, signs and abnormal anatomy. · Requires diet and medications to control their symptoms and have nutritional disorders but the weight stays in the normal range. 5.0-14.9

III • Includes patients with severe signs and symptoms and anatomical changes. • The diet and medications do not fully control the discomfort, weight loss occurs moderada.15-24.9

IV • Patients in this group have signs and symptoms of organ damage the stomach or duodenum with anatomical changes. · The complaints fail to be controlled with treatment, weight loss is moderate. 25-37.5

5.2.4 Pancreas

The most common chronic diseases of the pancreas irrecoverable are total or partial absence of the source gland surgery, recurrent pancreatitis and chronic pancreatitis, usually alcoholic origin. As cardinal symptoms are pain, sometimes intractable, and malabsorption with high-volume diarrhea, sometimes more than a liter a day, unlike the original intestinal malabsorption, diarrhea that occurs between 300 and 1,000 ml. day. They are usually people with various surgical procedures and high-volume fistulas.

TABLE NO. 5.4: CRITERIA FOR THE GLOBAL ASSESSMENT OF PANCREAS DEFICIENCY

Class Description of criteria Global Deficit (%)

I · are detected signs and symptoms of pancreatic and there is anatomic alteration. Do not require continuous treatment, the weight is kept at acceptable levels. 1.0-4.9

II · have symptoms and signs of organ damage, and anatomic abnormalities of the pancreas. · It requires ongoing treatment and dietary restrictions to control symptoms · It keeps the weight or, it is not lower than normal for the person. 5.0-14.9

III · have symptoms and signs of pancreatic injury is accompanied by anatomical changes. · Neither the control diet or drugs for the inconvenience, there is malnutrition and moderate weight loss. 15-24.9

IV · are presented severe symptoms and signs of pancreatic failure and anatomical lesion that is not controlled with treatment. • The weight loss is severe. • Must be included in this group of persons subjected to total pancreatectomy. 25-37.5

5.2.5 Small Intestine

The main symptoms and signs of changes in the small intestine are abdominal pain, bloating, bleeding, diarrhea, weight loss, weakness, vomiting, fever and anemia, among others.

TABLE No. 5.5: CRITERIA FOR THE GLOBAL ASSESSMENT OF DEFICIENCY OF SMALL INTESTINE

Class Description of criteria Global Deficit (%)

I • There are symptoms attributable to this segment of bowel but does not require continuous treatment and there is no weight loss. 1.0-4.9

II · have symptoms and signs of intestinal organ damage. · Requires regular diet and medications for their symptoms, weight loss does not exceed 10% of normal. 5.0-14.9

III · have symptoms and signs of intestinal injury with organ failure in this segment. · Neither drugs nor diet improve signs and symptoms completely. • The weight loss is moderate. 15-24.9

IV • There are marked symptoms and signs for anatomical lesion of the small intestine, which are not controlled by treatment and there is severe weight loss. 25-37.5

TABLE No. 5.6: SUMMARY OF CRITERIA FOR THE ASSESSMENT OF GLOBAL GAP upper digestive tract: esophagus, stomach, duodenum, small bowel and pancreas.Class I Class II Class III Class IV

Deficiency 1.0-4.9% -9.9% 5.0 Deficiency Deficiency Deficiency 10.0-22.4% 22.5-37.5% There are symptoms and signs of disease in the upper digestive apparatus or there is anatomic loss or alteration; there symptoms and signs of disease in upper digestive apparatus or there is anatomic loss or alteration; there symptoms and signs of disease in the upper digestive apparatus or there is anatomic loss or alteration; There are symptoms and signs of disease at the top of the appliance unit digestive or no alteration or loss anatomic YYYY

Continuous treatment is not required, is needed to keep diet and medication to control symptoms, signs of malnutrition or the latter two, the diet and medication completely control symptoms, signs, malnutrition and the latter two, the symptoms can not be controlled YYOO treatment

Maintaining normal weight, weight loss does not exceed the normal range. Weight loss is moderate range and is attributed to a disorder of the upper digestive tract. Weight loss is severe range and is attributed to a disorder of the upper digestive tract. O no sequelae after the operation. The following are some examples of diseases that are included in Class IV:

· Recurrent gastrointestinal bleeding and undetermined cause with anemia (hematocrit less than or equal to 30%)

· Stricture, stenosis or obstruction of the esophagus with severe weight loss;

· Peptic ulcer with recurrent ulceration, and definitive surgery persistent despite therapy, or inoperable fistula, or obstruction demonstrated by X-ray and endoscopy despite surgery or inoperable, or severe weight loss;

· Regional enteritis when persistent or recurrent intestinal obstruction evidenced by abdominal pain, bloating, nausea, vomiting and accompanied by areas of stenosis of the small intestine and proximal intestinal dilatation, or persistent systemic manifestations such as arthritis, iritis, fever, liver dysfunction not attributable to other causes, or intestinal obstruction

intermittent due to intractable abscess or fistula formation, or severe weight loss, or requiring permanent parenteral nutrition.

Colon and rectum 5.3TABLE No. 5.7: CRITERIA FOR THE ASSESSMENT OF GLOBAL GAPOF COLORECTAL

Class Description of criteria Global Deficit (%)

I · The symptoms and signs of disease of the colon or rectum are infrequent and of short duration. Do not work the individual is no limitation, or required diet or medication.

• There is no systematic manifestations and changes in weight or nutritional status. Do not have been consequences arising. 1.0-4.9

II · There is clearly a functional or anatomical alteration. • There are symptoms and signs of alteration of bowel function and moderate pain. · It requires minimal restriction in diet and systemic therapy. • There is no weight loss. 5.0-9.9

III • There are evidence of colonic or rectal disease or anatomical abnormality. • You have periods of exacerbation of symptoms ranging from mild to severe, with alterations in bowel function accompanied by periodic or continuous pain. • During the attacks is necessary to restrict their activities, special diet and medication. • There are general statements as

fever, anemia and weight loss moderate. 10.0-19.9

IV • There are objective evidence of disease of the colon or rectum and persistent discomfort, pain, limitation of physical activity. · It requires strict dietary restrictions and continuous medication not fully control the box. • There are general symptoms such as fever, anemia and severe weight loss, no long periods of remission. · Alterations in bowel function that persist at rest and accompanied by pain. 20.0-30.0

By way of example, belongs to Class IV, ulcerative colitis or granulomatous confirmed, with no improvement after total colectomy, or bloody stools and recurrent or persistent anemia confirmed by serial examinations with a hematocrit of 30% or less, or demonstrations recurrent or persistent systemic, such as arthritis, iritis, fever, liver dysfunction not attributable to other causes. U Intermittent bowel obstruction due to intractable abscess, fistula formation or stenosis, or severe weight loss.

Anal canal 5.4

The most frequent symptoms and signs of changes in the anal canal are alterations in continence, urgency to defecate, pain, tenesmus, rectal bleeding, diarrhea or constipation. Incontinence of neurological origin is discussed in that chapter.

TABLE No. 5.8: CRITERIA FOR THE ASSESSMENT OF GLOBAL GAP ANAL DUCTClass I Class II Class III

Deficiency Deficiency 2.5-7.4% 1.0-2.4% 7.5-12.5% ​​Deficiency There are signs of disease of the anal canal or no anatomic loss or alteration; There are signs of the anal canal disease or there is anatomic loss or alteration; There are signs of disease or anal canal there anatomic loss or alteration; OYY There slight incontinence of feces solids, liquids or both. Moderate fecal incontinence, but partial, which requires ongoing treatment, are complete fecal incontinence that requires continuous treatment, OOO

Pathological symptoms in the anal canal are mild, intermittent and yield to treatment. The symptoms persist and do not yield fully to treatment. Disease symptoms persist in the anal canal and can not be improved with treatment.

5.5 Surgical Ostomy

The permanent surgical stomata, usually are created to offset losses in anatomical and allow entry or egress of materials through the digestive tract. If a patient has a permanent surgical stoma, the following values ​​should be combined with the values ​​determined by the system involved.

TABLE No. 5.9: CRITERIA FOR ASSESSING DEFICIENCY BY GLOBAL SURGICAL STOMATA

Ostomy surgery Percentage of deficiency (%)

Esophagostomy 10

10 Gastrostomy

Jejunostomy 15

Ileosostomía15

Colostomy 10

Liver and biliary tract 5.6

The main signs and symptoms of the disease caused liver and bile duct are pain, jaundice, anorexia, nausea, vomiting, fatigue, weakness, weight loss, hematemesis, ascites, and altered consciousness.

5.6.1 Deficiency of the whole person by liver injury

TABLE No. 5.10: CRITERIA FOR THE GLOBAL ASSESSMENT OF DEFICIENCY OF LIVER INJURY

Class I Class II Class III Class IV

1.0-4.9% deficiency deficiency Deficiency 5-12.4% 12.5-24.9% 25-45% deficiency

Objective evidence of persistent liver disease but no symptoms, or history of ascites, jaundice, esophageal varices bleeding for three years, there is objective evidence of persistent liver disease but no symptoms, or history of ascites, jaundice, Esophageal variceal bleeding for three years, there is objective evidence of chronic progressive liver disease with history of jaundice, ascites, esophageal or gastric variceal bleeding, at least two episodes in the past year, there is objective evidence of progressive liver disease history of jaundice, ascites, esophageal varices and recurrent bleeding ogástricas and hepatic encephalopathy with symptoms; YYYY nutrition is good and there is fatigue or adynamia, no fatigue or malnutrition or adynamia. There may be malnutrition, fatigue and adynamia. There is malnutrition.

And I Biochemical tests show slight alteration of liver function biochemical tests show slight alteration to more liver damage than in class I. Intermittent ammonia poisoning or meat, or intermittent hepatic encephalopathy. Or are basic disorders in the metabolism of bilirubin.

5.6.1 Deficiency of the whole person Bile duct injury

TABLE No. 5.11: CRITERIA FOR ASSESSING DEFICIENCY BY GLOBAL BILIARY TRACT INJURIES

Class I Class II Class III Class IV

Gap 1 - 4.9% 5-12.4% Deficiency Deficiency Deficiency 12.5-24.9% 25-45% occasional episodes of malfunction of the bile ducts. There is a deficiency of bile duct recurrent despite treatment. Irreparable obstruction of the biliary tract with recurrent cholangitis. There is persistent jaundice and progressive and progressive liver disease due to common bile duct obstruction. By way of example, corresponds to class IV deficiency diseases of the liver and biliary tract such as Chronic Liver Disease and post-necrotic cirrhosis and portal bile chronic active hepatitis and Wilson's disease accompanied by esophageal varices endoscopically and radiologically proven, with a history of massive bleeding, or surgical bypass of these varices, or bilirubin 2.5 mg% or more on serial examinations for at least 5 months; or encephalopathy should be evaluated by the criteria applied in the chapter on Mental Illness, or confirmation of the existence of chronic liver biopsy and one of the following criteria:

· Ascites not attributable to other causes, recurrent or persistent for at least 3 months, demonstrated by abdominal ultrasound or clinical or associated with hypoalbuminemia of 3.0 g% or less. · Liver cell necrosis or inflammation of at least 3 months documented by hypoprothrombinemia (40%) and alteration of the enzymes that indicate liver dysfunction.

Overweight 5.7

Overweight is a state of physical abnormality that can be caused by disease. Physiological disorders can be accompanied to the magnitude of the failure and may condition or worsening of other diseases irrecoverable. Being overweight or obese themselves do not generate deficiency. Only allocated deficiencies according to the underlying disease that causes or its consequences, in those chapters, and should be combined to obtain the final total deficiency or see the combined values ​​table.

5.8 Other diseases of the abdominal wall

This group aims to highlight the group wall hernias and abdominal cavity, it can be corrected surgically and contraindications for this, in which case the deficiency is:

TABLE No. 5.12: CRITERIA FOR THE ASSESSMENT OF GLOBAL for other pathologies DEFICIENCY OF THE ABDOMINAL WALL

Hernias simple: global deficiency (%)

Inguinal, umbilical, femoral and other less frequent 1.0 - 2.5

Diaphragmatic hernia 2.4 - 4.9

Bilateral inguinal hernia 5.0 - 7.5

Inguinal-scrotal hernia 2.5 - 15.0

7.5 Recurrent Hernia

Other hernias Complex

Abdominal hernia 15.0 - 20.0

Hiatal Hernia with somatic symptoms and impact 20.0 - 25.0