GASTROENTEROlOGY

(J/

\.;" ~GASTRO~NTEST~NAL TABLE OF CONTENTS

I.~I.

FORM LET'1'ERCONDI'1'~ONSESOPHAGUS

Achalasia

Esophageal Tear (Mallory-Weiss Syndrome) (530.7)ESophagitis (530.1)..................................................Reflux (530.1) '."""""""""""'"""",

Stricture (530.3), Obstruction (530.3), Barrets Esophagus (530.2)Varices (456.1)......................................................

STOMACH AND DUODENUM

Gastrectomy (43.89).............Gastritis (535.5)...............................Peptic Ulcers (533)

Pyloric Stenosis (750.5)COLON

Appendicitis (541) ................Appendectomy (47.0)........................................Bowel Anastomosis (45.90).........Bowel Obstruction (560.9)............................................CoUtis, Ulcerative (556) ........Colon Resection (45.79)..........Colostomy (46.10)........................Crohn's Disease (Ileitis) (555.0) ........

Diverticular Disease (Diverticulitis (562.1), Diverticulosis)Ileostomy (46.20)....Intusseption (560.0).Irritable Bowel Syndrome (564.1)Lactose Intolerance (~71.3) ...

Polyps (211.3) .......Polypectomy (43.4.1)............................Proctocolpectomy' (45.79) ................

RECTUM AND ANUSAnal Fissure (565.0) .....................Anal Fistula (565.1) ...........Anorectal Abscess (566) .........Hemmorrhoidectomy (49 . 46) . . . . . . . . . . . . . . .

Hemorrhoids (455.6).............

Pilonidal Cyst (see Dermatology) (685.1)Proctitis

Infectious

".,.-.--

(530.0) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .GI-1

.GI-2

.GI-3

.GI-3

.GI-l

.GI-2,18

. . . . . . . . . . . .

... ......

. . . . . . . . . . . . . . . .GI-5

.GI-4

.GI-5

.GI-6

. . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ;. . .

...

. . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . .GI-14

. . . . . . .GI-14

. . . . . . . . . . . . . . . . . . . . . . . .GI-14

.GI-7

.GI-8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .GI-14

... ... . .GI-14

.GI-9

(562.10)GI-I0.. ... ... .. . . . ."... . ... .. . .GI-14

. . . . . . . . . . . . . . . . . . . . . .GI-7

. . . . . . . . . . . . . . . . . . . .GI-ll

.GI-12

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .GI-13

. . . . . . . . . . . . . . .GI-13

. . . . . . . . . . . . . .GI-14

................ . . . . . . . .

.

. . . . . .

. . . . . . . . . . . .". . .

. . . . . . .

. "'."" .

. . . . . .

.

.

. . . . . . . . . . . . . . . .GI-15

. . . . .GI-15

. .GI-15

. . . . . . . . . . . . . . . . . . . . . . . . . .GI-16

... .. . . . . . .GI~16

.....................

. . . . . . .

.

(569.49) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .GI-8

-.~

.),

"

Ulcerative (556) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .GI-BLIVER

Adenoma (211.5).. ~. . . . . . . .Ascites (789.5) ... ...Benign Liver CystsCirrhosis (571~5).;...........Hepatitis (070.97) (Codes A, B,

Chronic (571.4)......Other (573.3)........

. ... . .. .

.GI-17

.GI-18

.GI-17

.GI-18

.GI-19.GI-19.GI-19

..

(573.8) . . . . . . . . . . . . . . . ..

.....C see guidelines) . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . .. ... ... .

GALLBLADDER

Cholelithiasis (574.2) .GI-20Cholecystectomy(51.2) ;'.. . . . .. .GI-20Cholecystitis/Cholangitis (575.1) GI-20

PANCREASPancreatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ; . . . . . . . . . . . . . . . . . . . . . . .GI-21

Acute (577.0) GI-21Chronic (577.1) .GI-21

HERNIASHiatal (553.3)..............................................Paraesophageal (553.3)..........Repair (53.9)......Umbilical (553.1)..

Inguinal (550) '.""""""""'" ... .ADDENDUM

. . . . . . . . . . . . . . . . .

. .GI-22. . . . . . . . . . . . . . . . . . . . . . . . .GI-22. . . . . . . . . . . . . . . . . . . . . . . . .GI-22

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .GI -2 3. . . . .GI-23

.. .. .. ..III.

'C, .

::I.';!/':';'.

.~ ( (

.\"!.'

/

ACHALASIA (530.0), ESOPHAGEAL STRICTURE (530.3), OBSTRUCTION (530.3) OR BARRETT'S ESOPHAGUS (530.2)

CRITERIA

ACTION

RESTRIC-TIONS/DEFER

RATIONALE

1) Obstruction due to fo-reign object or benignneoplasm, resolvedwithout complications.

NIA H Achalasia, treated with I~pneumostatic dilation,2 yrs. post treatmentwithout recurrence.

Achalasia treated,period < 2 yrs. post.

~DEFER

UNTIL:

Two yrs. posttreatment andasymptomatic

1) Barrett's withDysplasia

2) Stricture

2) Barrett's Esophaguswithout Dysplasia(Endoscopy within 6mos. before departure)

~CLEAR

~CLEAR WITH

RESTRICTIONS

~MRB/MEDADVISOR

Treated Achalasia, 2yrs. post treatment issuccessful in 60 -80%of people.

3) Obstruction withpermanent damageto esophagus.

~MNQ

1) Barrett's Esophaguswith Dysplasia is athigh risk for develo-ping CA. Requiresclose FlU.

2&3) Requires inten-sivemedical regimen withrepeated dilatation.Care not available inPCMU's.

MEDICALINFORMATIONNEEDED:

Gastrointestinal

Endoscopy yearly withGastroenterologist, ifneeded.

Barrett's Esophagus: Precancerous condition caused bychronic esophageal reflux. Incidence of CA is low (10%).Needs 1 - 2 yr. endoscopic exam.

Generic Information.

Gastroenterologist evaluation.Endoscopy results for Barrett's Esophagus.

GI-1

5/4/93

CRITERIA

ACTION

RESTRIC.TIONS/DEFER

RATIONALE

ESOPHAGEAL TEAR (MALL .~Y.WEISSSYNDROME) (530.7)

History of, > 6 mos. ago. N/A Period < 6 mos.post episode. Associated with

Esophageal varices.

~CLEAR CLEAR WITH

RESTRICTIONSDEFER

~MNQ

Esophageal Varices are lifethreatening.

MEDICALINFORMATIONNEEDED:

Gastrointestinal

UNTIL:

Period> 6 mos. post episode.

Tear is caused by vomiting,hiccupping or wretching.

Generic information

GI-2

5/4/93

CRITERIA

ACTION

RESTRIC-TIONSIDEFER

RATIONALE

1) Single episode, 6 mos.asymptomaticwithoutmeds.

ESOPHAGITIS (530.1)

N/A

~CLEAR WITH

RESTRICTIONS

Medicationsused areZantac, Tagmet &Prilosec. They are veryeffectiveand safe, requireno special lab. work. Thepatient usually stays onthe medicationfor 6 mos.to life,first to cure thedisease then prevent anyrecurrence.

-,-

~ 1) GI bleeding associatedI

~ 1) Single episode withinwith esophagitis. last 6 mos.

2) Treatment withPrilosec (acid pumpinhibitor).

~MRSI MEDADVISOR

Prilosec cannot busedcontinuously. Often isused for severe,refractorypepticconditions.

~ 2) Recurrent episodes,symptoms unresolvedwith medications.

'~3) Surgery for Reflux < 6mos.

~DEFER

UNTIL:

1) Six months asympto-matic, off meds.

2) Six mos. controlledwith meds. (continuousor intermittent)

3) Six mos. post surgery.

1) HistoryofEsophagealHemorrhage due tovarices.

2) Recurrent episodes,readilycontrolledwithmeds or meds forprophylaxis.

~CLEAR

98% of Esophagitisiscaused by refluxbygastric contents intotheesophagus. --

Piliinduced or traumainduced Esophagitis healsrapidlywhen theoffendingsubstance isremoved or themedicationis stopped.

2) CorrosiveEsophagitis withstrictures

+MNQ

Appropriate medicalcare not available inPCMU's. At risk forsevere exacerbation.

MEDICALINFORMATIONNEEDED:

Gastrointestinal

Generic informationFlU needed next 3 yrs.; Diet restrictions;Endoscopy, UGI results, if available.

GI-3

5/4/93

CRITERIA

ACTION

RESTRIC-TIONS/DEFER

RATIONALE

1) Single episode, 6 mos.asymptomatic, with orwithoutmeds.

N/A

CLEAR WITHRESTRICTIONS

Meds. include Zantac,Tagamet, and Piilosec.They require no specialFlU.

GASTk__~d (535.5)

.-) 1) GI bleeding associated1

-) 1) Single episode not duewith gastritis. to NSAIDs < 6 mos.

2) Treatment withPrilosec (acid pumpinhibitor).

~MRB/MEDADVISOR

Prilosec cannot be usedcontinuously. Often isused for severe, refrac-tory peptic conditions.

N/A

H 2) Recurrent episode,symptoms unresolvedwith medications.Possiblyalcoholrelated.

~ ~

2) Recurrent episodes,readily controlledwithmeds or meds forprophylaxis.

~CLEAR

Avoid NSAIDs and aspirinIn the future.

DEFER MNQUNTIL:

Six months asymptomatic,meeting clearancerequirements.

MEDICALINFORMATIONNEEDED:

Gastrointestinal

Generic information; F/U needed next 3 yrs.

Stool for occult blood X 3; Diet limitations.

GI-410/2593

(.J ~PEPTIC ULCER DISEASE (PUD)(533), GASTRECTQMY (43.89)

RATIONALE

N/A

~CLEAR WITH

RESTRICTIONS

<I'

MedsIncludeZantac,Tagamet,Prllosec( < 1%failurerate). Medsareusedinitiallyas treatment,Ihenoftenfor 1 yr. to lifetimefor prophylaxis.< 10%relapserateIn firstyearwith medsas prophylaxis

~ 1) GI bleeding associatedI

-} 1) Duodenalulcer< 1 yrwith pepticulcer. ago

H 2) Treatmentwithprllosec(acidpumpinhibitor)

3) U\CtLt '

~C1'[[.P'-jJori)

-} 2) Benign gastric ulcer <1 yr. ~go,

-} 3) Gastrectomy < 1 yrago.

~DEFER

UNTIL:4}..Porlod> 1 yr, r9sol)'ed-2) Period> 1 yr.,

resolved;endoscopyshowscompletehealing..

3) Period> 1 yr.Prlloseccannotbe usedcontinuously.OftenIsusedforsevere,refractorypepticconditions.

~MRB/MEDADVISOR

~f'AQ P;VV~\~/q~

-} 1) Historyof perforationorhemorrhagewhileon treatment.

H 2) Partialgastrectomywith complications.

~MNQ

Treatment failure: atrisk for life threa-tening hemorrhage.

MEDICALINFORMATIONNEEDED:

Generic Information:

FlU needed next 3 yrs. mads.: Diet limitation.

Stoolfor occultblood X 3; Endoscopyresultsfor gastriculcer.,

Gastrointestinal GI-5

12/27/94

CRITERIA I-} 1) Duodenalulcer, Hresolved>1 yr. on oroffcontirfuousmeds.

-} 2) Benigngastriculcer,resolved>1 yr.,withcompletehealingonendoscopyor on or olfcontinuousmeds.

-} 3) PartialGastrectomy>1 yr ago,nocomplications.

(See Heme-3IfassociatedB12

ACTION deliClen1CLEAR

RESTRIC.TIONSIDEFER

PYLOlUC STENOSIS (750.5)

\ .

CRITERIA Hislory of, repair In Infancy '~ N/A'~

, '

.;. ',.: ..

ACTION CLEAR CLEARWITHRESTRICTIONS

RESTRIC-TIONS/DEFER

RATIONALE , '

!~

UNTIL:

N/A N/A

"

DEFER MNQ

MEDICAL:INFORMATIONNEEDED:

Gastrointestinal-.

.('..

GI-6

f (\I,

CRITERIA

ACTION

RESTRIC-TIONS/

.DEFER

RATIONALE

BOWEL OBSTRUCTION (560.9), INTUSSUSCEPTION (560.0)I

~ 1) Singleepisodebowelobstruction, resolvedmedically, period> 2 yrs.post

~ N/A

iCLEAR WITH

RESTRICTIONS

H 1) Bowel obstruction, benigncause, < 2 yrs. post medicaltreatment. .

~ 1) Intussusception (adultepisode) unless caused by apolyp or Mecklesdiverticulum.

~ 2) Bowel obstruction, benigncause, < 6 mos. post surgical ~ 2) Recurrent obstruction

unresolved by surgery.H 3) Cancer

iDEFER

UNTIL:

1) Five years post all treatment(inc!. radiation andchemotherapy) and CA free.

2) Can meet clear criteria.

1) Period> 2 yrs. no recurrence.

2) Period> 6 mos. norecurrence.

iMNQ

At high riskfor relapsewithdiarrheal episodes that arefrequent under Peace Corpsconditions.

MEDICALINFORMATIONNEEDED:

Gastrointestinal

,~ 2) Bowel obstruction resolvedsurgically without ostomy orwith no exterior appliancerequired for period> 6 mos.

~ 3) Intussusception in childhood

~ 4) Intussusception due to polypor Meckles diverticulumwhich was surgicallyremoved.

iCLEAR

Bowel obstruction can be caused bysimple mechanical obstructions.Adhesions, and strangulated hernia arethe most common. Can also occurassoc. with malignant neoplasms.

Generic information

GI-7

2/28/94

CRITERIA

ACTION

RESTRIC-TIONS/DEFER

RA TIONALE

COLITIS, ULCERATIVE (556), PROCTITIS (569.49)I

---t 1) Acute infectious proctitis,resolved. .

(excluding ulcerative colitis orCrohns colitis)

---tN/A Ulcerative proctitis or Hulcerative colitis,asymptomatic >1 0yrs without medication.

---t

---t 2) Acute colitis, one episode, 2yrs. asymp-tomatic, noevidence of recurrence,(excluding ulcerative colitis orChrons colitis).

---t

3) Post Proctocolectomy one yr.

ReturnedI normal functioning.CLEAR

~ ~

Post proctocolectomy< 1 yr.

~DEFER

> 1 yr. See GI-14 forspecific procedure

10% of patients withulcerative proctitisprogress to colitis.

~ Ulcerative proctitis orulcerativecolitis.

~MNQ

Pan-colon Disease:disease affects entirecolon, with history ofsteroid therapy, indicateshigh risk for relapse.

Complete remission inonly 1~~/oof cases~Numerous 'complicationsoccur: hemorrhage, toxiccolitis, toxic megacolon,CA of colon, fistulas.However, disease can bewell-controlled with'proper treatment.

MEDICALINFORMATIONNEEDED:

Gastrointes

CLEAR WITHRESTRICTIONS

MRSI MEDADVISOR

Proctocolectomy is totalcure. In colitis, risk ofdeveloping colon CAIncr,eases 10% per yr.Requires yearly colono-scopy starting 10 yrs. post

. diagnosis.

Generic information; Proctosigmoidoscopy results if done;Gastroenterologist evaluation for ulcerative colitis; extent of disease;FlU needed next 3 yrs.

('

10/25/93

CRITERIA

ACTION

RESTRIC.TIONS/DEFER

RATIONALE

COLITIS, ULCERATIVE (556), PR\..-.-' ns (569.49)

1) Acute infectious proctitis,resolved.(excluding ulcerative cqlitis orCrohnscolitis) ...

2) Acute colitis, one episode, 2yrs. asymp-tomatic, noevidence of recurrence,(excluding ulcerative colitis orChrons colitis).

H N/A Ulcerativeproctitisorulcerativecolitis,asymptomatic>10yrswithoutmedication.

Postproctocolectomy< 1 yr.

~DEFER

> 1 yr. See GI-14 forspecific procedure

10% of patients withulcerative proctitisprogress to colitis.

H Ulcerative proctitis orulcer.ativecolitis.

~MNQ

Pan-colon Disease:disease affects entirecolon,with historyof ..steroid therapy. Indicateshigh risk for relapse.

Complete remission inonly 10% of cases.Numerous complicationsoccur: hemorrhage, toxiccolitis, toxic megacolon,CA of colon, fistulas.However, disease can bewell-controlled withproper treatment.

MEDICALINFORMATIONNEEDED:

Gastrointestinal

3) Post Proctocolectomyoneyr.

Relumed! normal functioning.CLEAR

Proctocolectomy is totalcure. In colitis, risk ofdeveloping colon CAincreases 10% per yr:Requires yearly colono-scopystarting 10 yrs. postdiagnosis.

~ ~CLEAR WITH

RESTRICTIONSMRB/ MEDADVISOR

Generic information; Proctosigmoidoscopyresults if done;Gastroenterologist evaluationfor ulcerativecolitis; extentof disease;F/U needed next 3 yrs.

GI-B

10/25/93

CRITERIA

ACTION

RESTRIC-TIONS/DEFER

RATIONALE

CROON'S DISEASE (ILEITIS) (555.0)I

~ N/A ~ N/A H Minor disease, only 1episode> 5 yrs. ago,no meds, asymp-tomatic 5 yrs.

,~ Single episode, milddisease, period < 5yrs., asymptomatic.

~ 1) Chronic or recurrentCrohn's disease

~ 2) Complications:Renal, arthritis,fistula, abscesses.

+MNQ

Disease likely to exacer-bate and progress,placing PCV at risk forlife threatening episode.

Unlike colitis, no proventherapy for prophylaxisexists.

MEDiCALINFORMATIONNEEDED:

Gastrointestinal

+CLEAR

Single incident sometimescaused by bacteria(Yerslnia Enterocolitica).Then likely to havecomplete remission.

Crohn's Diseasevaries inseverity. Individual GIevaluation required.

Generic information

+CLEAR WITH

RESTRICTIONS

surgery is not total cure.Additional surgery issometimes required after7 - 10 yrs. However, ifasymptomatic after 5 yrs.,risk for relapse lessens.

+MRB/ MEDADVISOR

GI-9

+DEFER

UNTIL:

No recurrence> 5 yrs.

THEN:

MRB/MED Advisor

5/4/93

DIVERTICULAR DISEASE DIVERTIC'--_JSIS (562.10), DIVERTICULITIS (562.11)

N/A ~ N/A f-7 1) Diverticulitis,any episodenot surgically corrected.

~ 2) Diverticulosis,Hx of bleedingepisode

~CLEAR WITH

RESTRICTIONS

~DEFER MNQ

UNTIL:

ALE 1) 30 - 40% of people> 50 y.o.have diverticula. Theincidence increasesby 10%with each decade of life.

Repeated episodes of diverticulitishave potential for perforation, abs-cess, obstruction, fistula formation.Places PCV at risk for life threateningevent.

,LIATION):

Generic information

5/4/93

ltestinal GI-10

A 1) Diverticulosisincidental Idiagnosis on X-ray orendoscopy; no Hx of pain orbleeding.

2) Partial colectomy to removeinvolved portion of colon.

CLEAR

".,-

CRITERIA

ACTION

RESTRIC-TIONS/DEFER

RATIONALE

Self managed by diet, stress Hmanagement, with or withoutPM meds

CLEAR

Usually benign condition thatdoes not progress to colitis orileitis. Does not place PCV atrisk for dehydration or lifethreatening event. .

IRRIT ABLE BOWEL SYNDROME (IBS) (564.1)

N/A Not controlled with diet. stressmanagement, or medications.

N/A

~ ~ ~CLEAR WITH

RESTRICTIONSMNQDEFER

UNTIL:

Self managed as per "Clear"criteria.

IBS is a variable. chronic condition.Some individuals function totally normallyand others miss time from work and donot function well. Each applicant must beevaluated individually.

IBS does not place the PCV at added riskfor dehydration.

MEDICALINFORMATIONNEEDED:

Gastrointestinal

Generic information

GI-11

A

...",-

ALE

LACTOSE INl '- _~RANCE (271.3)

N/A Lactose intolerance N/A N/A

+

~LIATION>:

Itestinal

+ +CLEAR CLEAR WITH

RESTRICTIONS UNTIL:

No milk product diet

Lactose intolerance occurs inapprox. 75% of adults in allethnic groups except those ofnorthwest European origin forwhom the incidence Is < 20%.

Generic information

GI-12

+DEFER MNQ

5/4/93