The SSA considers digestive system disorders to fall into three broad categories: • Interference with nutrition, such as occurs with malabsorption syndromes. • Multiple recurrent inflammatory lesions, such as occur with inflammatory bowel diseases like regional enteritis. • Complications of disease, such as abscesses, fistulas, or intestinal obstruction.

1. L isting 5.02: Upper Gastrointestinal Bleeding (Adults)
This listing concerns only bleeding from the upper part of the GI tract, which means the esophagus, stomach, or small intestine. The most common causes of such bleeding are peptic ulcers and ruptured esophageal varices. Most sources of upper GI bleeding can be identified and controlled with treatment in far less than 12 months.

a. L isting Level Severity For your condition to be severe enough to meet the listing, you must have recurrent upper GI bleeding from an undetermined cause with anemia manifested by a hematocrit of 30% or less on repeated examinations. The SSA does not define the term “recurrent.” Medical judgment must be applied on an individual basis, depending on how much the disorder affects your ability to function. The more severe and prolonged the anemia, the fewer episodes it would take to be disabling. In order for the hematocrit to remain 30% or less for 12 months as a result of bleeding, there would either have to be persistent bleeding or fairly frequent episodes of bleeding.

2. L isting 5.03: Narrowing or Obstruction of the Esophagus (Adults)
Partial or complete obstruction of the esophagus can result from stenosis caused by stricture, tumors, or other diseases that injure the esophagus. For example, reflux esophagitis can damage the inner mucosal surface of the esophagus resulting in esophageal narrowing over a period of years. Connective tissue diseases such as progressive systemic sclerosis (PSS) can result in fibrotic degeneration of the esophagus so that it becomes narrowed. Whatever the cause, longterm narrowing of the esophagus even in the absence of complete obstruction may be severe enough to make adequate nutrition difficult. For purposes of the listing, the cause of esophageal obstruction is not as important as the malnutrition it causes.

a. L isting Level Severity For your condition to be severe enough to meet the listing, you must have partial or complete obstruction of the esophagus, by any disorder, that produces weight loss qualifying under Listing 5.08. The esophageal disorder must be documented with x-rays or by direct visualization with endoscopy.

3. L isting 105.03: Narrowing or Obstruction of the Esophagus (Children) The comments under Listing 5.03 apply here. Additionally, children may have congenital narrowing of the esophagus or even absence of the esophagus (esophageal atresia). Also, drinking caustic liquids like lye can cause severe scarring and consequent narrowing of the esophagus.

a. L isting Level Severity For a child’s condition to be severe enough to meet the listing, the child must have partial or complete obstruction of the esophagus by any disorder that produces weight loss qualifying under Listing 105.08. The esophageal disorder must be documented with x-rays or by direct visualization with endoscopy.

4. L isting 5.04: Peptic Ulcer Disease (Adults) Peptic ulcer disease (PUD) refers to ulcers in the stomach or duodenum occurring as a result of several factors, including digestive enzymes, stomach acid, and the presence of a particular type of bacteria (Helicobacteria pylori). The major risk of PUD is lifethreatening bleeding, and PUD is a frequent cause of upper GI bleeding. If an ulcer is known to be the source of bleeding, it can almost always be controlled. Unknown causes of bleeding are considered under Listing 5.02. The listing requires that PUD be proven, not merely suspected. That requires x-rays by an upper gastrointestinal series or endoscopy.

a. L isting Level Severity For your condition to be severe enough to meet the listing, you must have peptic ulcer disease as demonstrated by x-rays or by direct visualization with endoscopy. Additionally, you must satisfy A, B, C, or D, below. A Recurrent ulceration after definitive surgery persistent despite therapy. The recurrence must be demonstrated by x-rays or endoscopy, just as the original ulcer must be proven to exist. Impairment resulting from ulcer recurrence must be expected to last 12 months. Definitive surgery is that which was intended to control the ulcer, such as vagotomy and pyloroplasty or partial (subtotal) gastrectomy. B Inoperable fistula. For example, an ulcer might penetrate from inside to outside of the small intestine where it starts and then penetrate from outside to inside of another nearby piece of intestine. This could leave a fistula between the insides of the two areas of intestine that would normally not be present. Or the ulcer could penetrate the intestine and become attached to the pancreas, resulting in a fistula between the two. This would be a quite serious and painful situation. A fistula might be inoperable if, for example, scarring from the ulcer and prior surgeries contraindicate attempts at further repair. C Recurrent obstruction of the intestine demonstrated on x-rays or endoscopy. Such obstruction would most likely be caused by scarring related to the ulcer, even if the ulcer itself were successfully treated. Ulcers that occur repeatedly are probably more likely to result in this situation, as well as larger ulcers. D Weight loss as described under Listing 5.08. Malnutrition could be an issue with PUD. It is important that your weight be accurately measured without shoes or other significant clothing that would falsely add to your weight and work to your disadvantage.

5. L isting 5.05: Chronic Liver Disease (Adults) Most adult claimants alleging disability on the basis of liver disease have alcoholic liver damage, either as alcoholic liver inflammation (alcoholic hepatitis) or fibrous shrinkage of the liver secondary to alcohol abuse known as alcoholic cirrhosis. Many other disorders can damage the liver, including genetic disorders, toxins, poisons, drugs, bacterial infections, heart failure, fungi, ulcerative colitis, parasites, and viruses. Viral hepatitis may be caused by hepatitis viruses A, B, C, D, E, or G. Other viral infections can affect the liver but are not classified as viral hepatitis types. Chronic active hepatitis and chronic persistent hepatitis can result from infectious or toxic insults to the liver.

a. L isting Level Severity For your condition to be severe enough to meet the listing, you must have chronic liver disease. Additionally, you must satisfy A, B, C, D, E, or F, below. A Esophageal varices (demonstrated by x-rays or endoscopy) with a documented history of massive hemorrhage attributable to these varices. You would be considered disabled for three years following the last massive hemorrhage; thereafter, the SSA would evaluate the residual impairment. This listing recognizes that portal hypertension resulting from cirrhosis can cause varicose veins in the esophagus, which then have a tendency to bleed. The SSA does not define massive hemorrhage, but hospitalization and blood transfusion would probably be required. B Performance of a shunt operation for esophageal varices. You would be considered disabled for three years following surgery; thereafter, the SSA would evaluate the residual impairment. You satisfy this listing if your condition is so severe that you required surgery for a shunt operation—such as a portacaval shunt—to decrease pressure in your portal venous system and lower the risk of bleeding from esophageal varices. C Serum total bilirubin of 2.5 mg/100 ml (2.5 mg/ deciliter) or greater that persists on repeated examinations for at least five months. Total bilirubin is divided into direct (conjugated) and indirect (unconjugated) bilirubin. The SSA must use the total; partial values will be lower and your claim could be erroneously denied. The SSA does not define repeated examinations; medical judgment must be applied. must be made sometime near the beginning and end of the five-month period. D Ascites, not attributable to other causes, recurrent or persisting for at least five months, demonstrated by abdominal paracentesis or associated with hypoalbuminemia of 3.0 grams/100 ml (3.0 grams/deciliter) or less. Ascites can be suspected on physical examination by a doctor; however, the listing requires confirmation by paracentesis (done by your treating doctor) or by measurement of blood albumin. Albumin tends to decline when you have ascites. E Hepatic encepalopathy. This would be evaluated under the criteria of mental disorder listing 12.02 (Chapter 27). Hepatic encephalopathy is a state of confusion associated with elevated levels of blood ammonia, which the diseased liver cannot handle. F Confirmation of chronic liver disease by liver biopsy. Because the SSA will not order you to undergo a liver biopsy, this listing applies only if your treating doctor has done one. You must also satisfy 1, 2, or 3. 1. Ascites, not attributable to other causes, recurrent or persisting for at least three months, demonstrated by abdominal paracentesis or associated with hypoalbuminemia of 3.0 grams/100 ml (3.0 grams/deciliter) or less. This is the same as part D, except only three months is required. 2. Serum total bilirubin of 2.5 mg/100 ml (2.5 mg/ deciliter) or greater on repeated examinations for at least three months. This is the same as part C, except only three months is required. 3. Hepatic cell death (necrosis) or inflammation (hepatitis), persisting for at least three months, documented by repeated abnormalities of prothrombin time (PT) and elevated enzymes indicative of liver dysfunction. Laboratories varyAdvanced liver disease with extremely high bilirubin blood levels would most likely last at least five months, but this is affected by the prognosis for the particular liver disease. In all cases, a blood test of bilirubin levels widely on the expected normal values of hepatic enzymes because of differences in measurement techniques. Test report results, however, should include normal values against which the results can be compared. It is not necessary that all of the various types of enzymes be measured. AST or ALT would normally be sufficient.

6. L isting 105.05: Chronic Liver Disease (Children) Many disorders can damage a child’s liver, including genetic disorders, toxins, poisons, drugs, bacterial infections, heart failure, fungi, ulcerative colitis, parasites, and viruses. Viral hepatitis may be caused by hepatitis viruses A, B, C, D, E, or G. Other viral infections can affect the liver but are not classified as viral hepatitis types. Chronic active hepatitis and chronic persistent hepatitis can result from infectious or toxic insults to the liver.

a. L isting Level Severity For the child’s condition to be severe enough to meet the listing, the child must have chronic liver disease. Additionally, the child’s condition must satisfy A, B, C, D, E, or F, below. A Inoperable biliary atresia demonstrated by x-ray or surgery. Biliary atresia is a genetic disorder characterized by an absent bile duct system in the liver. B Ascites not responding to treatment and not attributable to other causes. A serum albumin of 3.0 grams/100 ml (3.0 grams/deciliter) or less must also be present. Ascites is a sign of advanced liver disease and will result in a low serum albumin blood test. C Esophageal varices demonstrated by angiography, barium swallow, endoscopy, or by prior performance of a specific shunt or plication procedure. If one of the tests does not show the disease, a shunt or plication procedure is sufficient proof because the surgery otherwise would not have been performed. Unlike adults, bleeding from the varices is not required. D Hepatic coma, documented by findings from hospital records. E Hepatic encephalopathy evaluated under mental Listing 112.02. (See Chapter 27.) F Chronic active inflammation or liver cell death documented by an SGOT, persistently measuring 100 units or a serum bilirubin of 2.5 mg/100 mg (2.5 mg/deciliter or 2.5 mg/dl) or greater.

7. L isting 5.06: Chronic Ulcerative or Granulomatous Colitis (Adults) Ulcerative and granulomatous colitis are inflammatory diseases of unknown cause that affect the large intestine. They may be associated with several symptoms and other abnormalities that result in disability. The diagnosis must be first established by one of the methods mentioned in the listing, however.

a. L isting Level Severity For your condition to be severe enough to meet the listing, you must have chronic ulcerative or granulomatous colitis (demonstrated by endoscopy, barium enema, biopsy, or operative findings) along with A, B, C, D, or E, below. A Recurrent bloody stools documented on repeated examinations and anemia manifested by a hematocrit of 30% or less on repeated examinations. Bloody stools not only indicate uncontrolled disease, but also can result in significant blood loss. The SSA does not define recurrent; medical judgment is applied case by case. The more severe and prolonged the anemia, the fewer episodes would be required to be disabling. A minimum of three different hematocrits, reasonably spread out over three to six months, is required to conclude that the severity will last a year. B Persistent or recurrent systemic manifestations, such as arthritis, iritis, fever, or liver dysfunction, not attributable to other causes. The SSA does not define recurrent; medical judgment is applied case by case. The more severe and prolonged the abnormalities, the fewer episodes would be required for the disease to be disabling. C Intermittent obstruction due to abscesses, fistula formation, or narrowing of the intestine that does not respond to treatment. The SSA does not define intermittent; medical judgment must be applied case by case. The more severe and prolonged the abnormalities, the fewer episodes would be required for the disease to be disabling. D Recurrence of findings of part A, B, or C after total colectomy. The colon is called the target organ for ulcerative or granulomatous colitis, and improvement would normally be expected after its removal. Recurrence, even once, of any of the abnormalities Listed in part A, B, or C despite colectomy is a sign of continuing disabling severity. E Weight loss as described under Listing 5.08. Malnutrition with significant weight loss can be a significant problem. Your weight must be accurately measured without shoes or other significant clothing that would falsely add to your weight and work to your disadvantage.

8. L isting 5.07: Regional Enteritis (Adults) Regional enteritis is an inflammatory disease of unknown cause affecting the small intestine. When regional enteritis affects only the large intestine it is known as granulomatous colitis, which is evaluated under Listing 5.06. When regional enteritis affects both the small and large intestines it is known as ileocolitis, which can be evaluated under either listing.

a. L isting Level Severity For your condition to be severe enough to meet the listing, you must have regional enteritis (demonstrated by findings during surgery, endoscopy, x-rays with barium contrast, or biopsy). Additionally, you must satisfy part A, B, C, or D below. A Persistent or recurrent intestinal obstruction. The SSA must have evidence of clinical abnormalities expected of obstruction— abdominal pain, abdominal distention, nausea, and vomiting. X-ray findings of obstruction must also be present: dilation of the intestine just before the obstruction. Obstruction results from the inflammatory nature of the disease that can produce scarring, abscesses, or fistulas. The SSA does not define recurrent; medical judgment must be applied case by case. The more severe and prolonged your abnormalities, the fewer episodes would be required to be considered disabling. B Persistent or recurrent systemic manifestations such as arthritis, iritis, fever, or liver dysfunction, not attributable to other causes. The SSA does not define recurrent; medical judgment must be applied case by case. The more severe and prolonged the abnormalities, the fewer episodes would be required to be disabling. C Intermittent intestinal obstruction due to abscess or fistula formation. Unlike part A, clinical abnormalities such as nausea and vomiting are not required. The SSA does not define recurrent; medical judgment must be applied case by case. The more severe and prolonged the abnormalities, the fewer episodes would be required to be disabling. D Weight loss as described under Listing 5.08. Malnutrition with significant weight loss can be a significant problem. Your weight must be accurately measured without shoes or other significant clothing that would falsely add to your weight and work to your disadvantage.

9. L isting 105.07: Chronic Inflammatory Bowel Disease (Children) Chronic inflammatory bowel disease (chronic IBD) usually means ulcerative colitis, regional enteritis, or granulomatous colitis. Any inflammatory disorder of the intestine, however, could qualify. In addition to the complications that can afflict adults with IBD, children may also suffer decreased growth as a result of such chronic disease.

a. L isting Level Severity For the child’s condition to be severe enough to meet the listing, the child must have chronic inflammatory bowel disease ( demonstrated by findings during surgery, endoscopy, x-rays with barium contrast, or biopsy). Additionally, the child’s condition must satisfy A, B, or C, below. A Intestinal manifestations or complications, such as obstruction, abscess, or fistula formation that has lasted or is expected to last 12 months. B Malnutrition as described under Listing 105.08. C Growth impairment as described in Listing 100.03

10. L isting 5.08: Weight Loss (Adults) Weight loss is a potentially disabling problem that most digestive system disorders have in common. A wide variety of medical problems can result in weight loss; it is very important in disability determination. When medical evidence has established a primary or secondary digestive tract disorder, the resultant interference with nutrition is considered under this listing. The difference between primary or secondary digestive disorders is made by the SSA, but it is not necessary for you to understand. You just need to know that any physical disorder that sufficiently interferes with the function of the digestive tract can potentially satisfy this listing. Examples of primary gastrointestinal (GI) disorders that can cause weight loss include: • Various forms of inflammatory bowel disease, such as regional enteritis and ulcerative colitis. • Inflammation of the mucosa lining the inside of the intestines. • Chronic inflammation of the pancreas (chronic pancreatitis). When the pancreas is damaged, it cannot produce the digestive enzymes needed for digestion or absorption. • Surgical removal of stomach or intestine (gastrointestinal resection). This can result in a limited ability to intake adequate amounts of food as well as a decrease in the amount of intestine available for the digestion of food and the absorption of food nutrients. • Esophageal stenosis, including narrowing caused by scarring (stricture). • Disorders resulting in the intestinal mucosa’s malabsorption of nutrients, including bacterial growth in the small intestine, drugs, genetic diseases, damage by radiation, parasitic infections, diabetes mellitus, inflammatory bowel diseases, autoimmune disorders, and surgery on the GI tract. Decreased pancreatic function, such as that caused by cystic fibrosis, may also result in malabsorption. • Disorders resulting in the body’s malassimilation of nutrients, including chronic kidney failure and cancer. Type I diabetes mellitus can also cause malassimilation. • Obstructions in the digestive tract such as by tumors, abscesses, or stenosis that interfere with the ability to get food to locations where it can be properly digested and absorbed. For example, chronic peptic ulcer disease (PUD) may cause not only pain that discourages adequate food intake, but also scarring in the stomach or upper part of the small intestine which interferes with food transit from the stomach into the intestines. • Loss of appetite accompanying digestive system disorders. Chronic illness itself may cause anorexia. • Pain associated with digestive disorders causing restriction of food intake, especially if eating causes increased pain. Most serious digestive system disorders cause pain. Weight loss caused by nondigestive system impairments, such as hormonal or mental disorders, should be evaluated under the appropriate listings for those disorders. One exception is Type I (juvenile) diabetes, a hormonal disorder caused by the immune system’s damage to the insulin-producing cells of the pancreas with resultant decrease in the production of insulin and an abnormal metabolic state. Type I diabetes is considered by part B4 of the listing. Understand that Type II (adult onset) diabetes is a different disease, and usually associated with obesity, not weight loss. Another exception is the serious mental disorder known as anorexia nervosa. A person with anorexia nervosa would probably be granted benefits under a mental disorder listing. In addition, persistence of weight loss under Tables I or II (part A of the listing) is justification for an allowance, even with no physical disorder.

a. L isting Level Severity For your condition to be severe enough to meet the listing, you must have weight loss due to any persisting gastrointestinal disorder. (The weights in Tables I–IV must have persisted for at least three months despite prescribed therapy and must be expected to persist for at least 12 months.) You must also satisfy A or B, below. Note that the tables list whole numbers only. Many people’s heights or weights fall in between the figures given in the tables. If your height is one-half inch or more over a value, the SSA should use the next higher value. For example, if you are 67.5 inches, consider yourself 68 inches. This is to your advantage in that you can weigh three pounds more at 68 inches than 67 inches and still qualify under the listing. If your weight is less than one-half of a value, the SSA should use the lower value. For example, if you weigh just under 109.5 pounds, consider yourself 109 pounds. Paying attention to such details can easily make the difference between being granted and being denied benefits. Say you are a male with the height and weight given above, 67.5 inches and 109.5 pounds. Without rounding off both values, you would fail to qualify under Table I; by rounding off you would be granted benefits. Do not assume that the SSA will pay attention to such detail.

11. L isting 105.08: Weight Loss (Children) The comments under Listing 5.08 regarding gastrointestinal disorders apply here. Because a child’s normal weight varies with age, percentile rankings are used instead of tables of weights. A child old enough—such as a teenager—to satisfy the heights in Tables I–IV of Listing 5.08 can be evaluated under that listing. Any doctor who treats children should have a standard growth chart. You child’s doctor should also have a record of your child’s weight at different ages. If the doctor has not kept good records, your child’s disability decision could be delayed, because the SSA needs several weights over a period of months to verify the persistence of the malnutrition.

a. L isting Level Severity For the child’s condition to be severe enough to meet the listing, the child must have malnutrition due to gastrointestinal disease with either: • weight loss resulting in a fall of at least 15 percentiles on standard growth charts which persists, or • persistence of weight that is less than the third percentile on standard growth charts. Additionally, the child’s condition must satisfy A, B, C, or D, below. A Stool fat excretion per 24 hours satisfying 1, 2, or 3. 1. More than 15% in infants less than six months. 2. More than 10% in infants six to 18 months. 3. More than 6% in children more than 18 months. B Persistent hematocrit of 30% or less despite prescribed therapy. C Serum carotene of 40 micrograms (mcg)/100 ml or less. D Serum albumin of 3.0 grams/100 ml or less.

12. Listing 5.09: Liver Transplant (Adults) About 87% of patients survive for one year after a liver transplant. At five years, the post-transplant survival rate decreases by approximately 10%. In adults, acquired disorders like alcoholic cirrhosis and viral hepatitis are the main causes of liver failure and the need for transplantation. In children, liver failure is more commonly caused by a genetic disorder (especially failure of the bile ducts to develop, a disorder known as biliary atresia). Although most livers are transplanted from deceased donors, an increasingly popular option is to receive part of a living donor’s liver. As with other types of organ transplants, the major problem is suppression of the immune system, a deliberate medical step to prevent rejection of the graft. Unfortunately, this suppressed immunity can lead to the development of serious infections: viral, fungal, bacterial, and parasitic. Immune suppression also increases the chances of developing cancer, particularly lymphoma. Other side effects of the medications and other risks are the same as those found with all organ transplants, such as the development of osteoporosis, cataracts (resulting from corticosteroids), intense itching, kidney and brain toxicity, nausea, vomiting, diabetes, and high blood pressure. Liver transplants require close monitoring for immune rejection and other complications, particularly infections. The first year after transplantation is particularly important, although problems can develop at any time.

a. Listing Level Severity If you have had a liver transplant, the SSA will automatically consider you to be disabled for one year following surgery. After that, your residual impairment will be evaluated under whatever listings are appropriate to your particular situation, such as those covering the digestive system. You qualify for these first 12 months of disability benefits without any restrictions whatsoever. For example, you could be feeling great eight months after surgery and your doctor could even tell the SSA she thinks you could work. But you would still qualify under the listing, if you wished to make use of your benefits.

13. Listing 105.09: Liver Transplant (Children) The comments under Listing 3.11 for adults apply here, even though the particular types of liver disease that may lead to a transplant often differ in children.

a. Listing Level Severity A child is considered disabled for one year following surgery and, like adults, no other medical factors can alter this qualification. After that, the child’s residual impairment is evaluated under whatever digestive system or other listings are appropriate.