TN 22 (01-17)
5.00 DIGESTIVE SYSTEM (Effective Date: 12/18/07)
A. What kinds of disorders do we consider in the digestive system? Disorders of the digestive system include gastrointestinal hemorrhage, hepatic (liver)
dysfunction, inflammatory bowel disease, short bowel syndrome, and malnutrition. They
may also lead to complications, such as obstruction, or be accompanied by manifestations
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 medically acceptable imaging studies
and reports of endoscopy, operations, and pathology, as appropriate to each listing,
to document the severity and duration of your digestive disorder. Medically acceptable
imaging includes, but is not limited to, x-ray imaging, sonography, computerized axial
tomography (CAT scan), magnetic resonance 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 considering in connection with your application or continuing disability review.
C. How do we consider the effects of treatment?
1. Digestive disorders frequently respond to medical 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 laboratory 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 supplemental 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 temporary or long-term, in most cases we
need information 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 disorder, 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 community 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 medical 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 of the digestive
system listings, but your digestive impairment may medically equal a listing or be
disabling based on consideration of your residual functional 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 (suppression 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
transplantation 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), primary biliary cirrhosis (PBC), primary sclerosing cholangitis
(PSC), autoimmune hepatitis, hemochromatosis, 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 severity of liver disease and functional ability.
b. Signs may include, but are not limited to, jaundice, 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 demonstrate the degree of liver cell necrosis,
inflammation, 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, ultrasound, MRI) may show the size and consistency
(fatty liver, scarring) of the liver and document ascites (see 5.00D6).
4. Chronic viral hepatitis infections.
(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 findings (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 varies considerably based on medication tolerance, treatment response,
adverse effects of treatment, and duration of the treatment. Comorbid disorders, such
as HIV infection, may accelerate the clinical course of viral hepatitis infection(s)
or may result in a poorer 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.
b. Chronic hepatitis B virus (HBV) infection.
(i) Chronic HBV infection can be diagnosed by the detection of hepatitis B surface antigen (HBsAg) or hepatitis
B virus DNA (HBV DNA) in the blood for at least 6 months. In addition, detection of
the hepatitis B e antigen (HBeAg) suggests an increased likelihood of progression
to cirrhosis, ESLD, and hepatocellular carcinoma. (HBeAg may also be referred to as
“hepatitis B early antigen”or “hepatitis B envelope
(ii) The therapeutic goal of treatment is to suppress HBV replication and thereby
prevent progression to cirrhosis, ESLD, and hepatocellular carcinoma. Treatment usually
includes interferon injections, oral antiviral agents, or a combination of both. Common
adverse effects of treatment are the same as noted in 5.00D4c(ii) for HCV, and generally
end within a few days after treatment is discontinued.
c. Chronic hepatitis C virus (HCV) infection.
(i) Chronic HCV infection is diagnosed by the detection of hepatitis C viral RNA in the blood for at least
6 months. Documentation of the therapeutic response to treatment is also monitored
by the quantitative assay of serum HCV RNA (“HCV viral
load”). Treatment usually includes a combination of interferon injections and oral ribavirin;
whether a therapeutic response has occurred is usually assessed after 12 weeks of
treatment by checking the HCV viral load. If there has been a substantial reduction
in HCV viral load (also known as early viral response, or EVR), this reduction is
predictive of a sustained viral response with completion of treatment. Combined therapy
is commonly discontinued after 12 weeks when there is no early viral response, since
in that circumstance there is little chance of obtaining a sustained viral response
(SVR). Otherwise, treatment is usually continued for a total of 48 weeks.
(ii) Combined interferon and ribavirin treatment may have significant adverse effects
that may require dosing reduction, planned interruption of treatment, or discontinuation
of treatment. Adverse effects may include: Anemia (ribavirin-induced hemolysis), neutropenia,
thrombocytopenia, fever, cough, fatigue, myalgia, arthralgia, nausea, loss of appetite,
pruritis, and insomnia. Behavioral side effects may also occur. Influenza-like symptoms
are generally worse in the first 4 to 6 hours after each interferon injection and
during the first weeks of treatment. Adverse effects generally end within a few days
after treatment is discontinued.
d. Extrahepatic manifestations of HBV and HCV. In addition to their hepatic manifestations, both HBV and HCV may have significant
extrahepatic manifestations in a variety of body systems. These include, but are not
limited to: Keratoconjunctivitis (sicca syndrome), glomerulonephritis, skin disorders
(for example, lichen planus, porphyria cutanea tarda), neuropathy, and immune dysfunction
(for example, cryoglobulinemia, Sjögren’s syndrome, and vasculitis). The extrahepatic
manifestations of HBV and HCV may not correlate with the severity of your hepatic
impairment. If your impairment(s) does not meet or medically equal a listing in an
affected body system(s), we will consider the effects of your extrahepatic manifestations
when we assess your residual functional capacity.
5. Gastrointestinal hemorrhage (5.02 and 5.05A). Gastrointestinal hemorrhaging can result in hematemesis (vomiting
of blood), melena (tarry stools), or hematochezia (bloody stools). Under 5.02, the
required transfusions of at least 2 units of blood must be at least 30 days apart
and occur at least three times during a consecutive 6-month period. Under 5.05A, hemodynamic instability is diagnosed with signs such as pallor (pale skin), diaphoresis (profuse perspiration),
rapid pulse, low blood pressure, postural hypotension (pronounced fall in blood pressure
when arising to an upright position from lying down) or syncope (fainting). Hemorrhaging
that results in hemodynamic instability is potentially life-threatening and therefore
requires hospitalization for transfusion and supportive care. Under 5.05A, we require
only one hospitalization for transfusion of at least 2 units of blood.
6. Ascites or hydrothorax (5.05B) indicates significant loss of liver function due to chronic liver disease.
We evaluate ascites or hydrothorax that is not attributable to other causes under
5.05B. The required findings must be present on at least two evaluations at least
60 days apart within a consecutive 6-month period and despite continuing treatment
7. Spontaneous bacterial peritonitis (5.05C) is an infectious complication of chronic liver disease. It is diagnosed by
ascitic peritoneal fluid that is documented to contain an absolute neutrophil count
of at least 250 cells/mm3. The required finding in 5.05C is satisfied with one evaluation documenting peritoneal
fluid infection. We do not evaluate other causes of peritonitis that are unrelated
to chronic liver disease, such as tuberculosis, malignancy, and perforated bowel,
under this listing. We evaluate these other causes of peritonitis under the appropriate
body system listings.
8. Hepatorenal syndrome (5.05D) is defined as functional renal failure associated with chronic liver disease
in the absence of underlying kidney pathology. Hepatorenal syndrome is documented
by elevation of serum creatinine, marked sodium retention, and oliguria (reduced urine
output). The requirements of 5.05D are satisfied with documentation of any one of
the three laboratory findings on one evaluation. We do not evaluate known causes of
renal dysfunction, such as glomerulonephritis, tubular necrosis, drug-induced renal
disease, and renal infections, under this listing. We evaluate these other renal impairments
9. Hepatopulmonary syndrome (5.05E) is defined as arterial deoxygenation (hypoxemia) that is associated with
chronic liver disease due to intrapulmonary arteriovenous shunting and vasodilatation
in the absence of other causes of arterial deoxygenation. Clinical manifestations
usually include dyspnea, orthodeoxia (increasing hypoxemia with erect position), platypnea
(improvement of dyspnea with flat position), cyanosis, and clubbing. The requirements
of 5.05E are satisfied with documentation of any one of the findings on one evaluation.
In 5.05E1, we require documentation of the altitude of the testing facility because
altitude affects the measurement of arterial oxygenation. We will not purchase the
specialized studies described in 5.05E2; however, if you have had these studies at
a time relevant to your claim, we will make every reasonable effort to obtain the
reports for the purpose of establishing whether your impairment meets 5.05E2.
10. Hepatic encephalopathy (5.05F).
a. General. Hepatic encephalopathy usually indicates severe loss of hepatocellular function.
We define hepatic encephalopathy under 5.05F as a recurrent or chronic neuropsychiatric
disorder, characterized by abnormal behavior, cognitive dysfunction, altered state
of consciousness, and ultimately coma and death. The diagnosis is established by changes
in mental status associated with fleeting neurological signs, including “flapping tremor”(asterixis), characteristic electroencephalographic (EEG) abnormalities, or abnormal
laboratory values that indicate loss of synthetic liver function. We will not purchase
the EEG testing described in 5.05F3b; however, if you have had this test at a time
relevant to your claim, we will make every reasonable effort to obtain the report
for the purpose of establishing whether your impairment meets 5.05F.
b. Acute encephalopathy. We will not evaluate your acute encephalopathy under 5.05F if it results from conditions
other than chronic liver disease, such as vascular events and neoplastic diseases.
We will evaluate these other causes of acute encephalopathy under the appropriate
body system listings.
11. End stage liver disease (ESLD) documented by scores from the SSA Chronic Liver Disease (SSA CLD) calculation (5.05G).
a. We will use the SSA CLD score to evaluate your ESLD under 5.05G. We explain how
we calculate the SSA CLD score in b. through g. of this section.
b. To calculate the SSA CLD score, we use a formula that includes three laboratory
values: Serum total bilirubin (mg/dL), serum creatinine (mg/dL), and International
Normalized Ratio (INR). The formula for the SSA CLD score calculation is:
9.57 x [Loge(serum creatinine mg/dL)]
+3.78 x [Loge(serum total bilirubin mg/dL)]
+11.2 x [Loge(INR)]
c. When we indicate “Loge”in the formula for the SSA CLD score calculation, we mean the “base
e logarithm”or “natural logarithm”(ln) of a numerical laboratory value, not the “base 10 logarithm”or “common
logarithm”(log) of the laboratory value, and not the actual laboratory value. For example, if
an individual has laboratory values of serum creatinine 1.2 mg/dL, serum total bilirubin
2.2 mg/dL, and INR 1.0, we would compute the SSA CLD score as follows:
9.57 x [Loge(serum creatinine 1.2 mg/dL) = 0.182]
+3.78 x [Loge(serum total bilirubin 2.2 mg/dL) = 0.788]
+11.2 x [Loge(INR 1.0) = 0]
= 1.74 + 2.98 + 0 + 6.43
= 11.15, which is then rounded to an SSA CLD score of 11.
d. For any SSA CLD score calculation, all of the required laboratory values must have
been obtained within 30 days of each other. If there are multiple laboratory values
within the 30-day interval for any given laboratory test (serum total bilirubin, serum
creatinine, or INR), we will use the highest value for the SSA CLD score calculation.
We will round all laboratory values less than 1.0 up to 1.0.
e. Listing 5.05G requires two SSA CLD scores. The laboratory values for the second
SSA CLD score calculation must have been obtained at least 60 days after the latest
laboratory value for the first SSA CLD score and within the required 6-month period.
We will consider the date of each SSA CLD score to be the date of the first laboratory
value used for its calculation.
f. If you are in renal failure or on dialysis within a week of any serum creatinine
test in the period used for the SSA CLD calculation, we will use a serum creatinine
of 4, which is the maximum serum creatinine level allowed in the calculation, to calculate
your SSA CLD score.
g. If you have the two SSA CLD scores required by 5.05G, we will find that your impairment
meets the criteria of the listing from at least the date of the first SSA CLD score.
12. Liver transplantation (5.09) may be performed for metabolic liver disease, progressive liver failure, life-threatening
complications of liver disease, hepatic malignancy, and acute fulminant hepatitis
(viral, drug-induced, or toxin-induced). We will consider you to be disabled for 1
year from the date of the transplantation. Thereafter, we will evaluate your residual
impairment(s) by considering the adequacy of post-transplant liver function, the requirement
for post-transplant antiviral therapy, the frequency and severity of rejection episodes,
comorbid complications, and all adverse treatment effects.
E. How do we evaluate inflammatory bowel disease (IBD)?
1. Inflammatory bowel disease (5.06) includes, but is not limited to, Crohn’s disease and ulcerative colitis. These
disorders, while distinct entities, share many clinical, laboratory, and imaging findings,
as well as similar treatment regimens. Remissions and exacerbations of variable duration
are the hallmark of IBD. Crohn’s disease may involve the entire alimentary tract from
the mouth to the anus in a segmental, asymmetric fashion. Obstruction, stenosis, fistulization,
perineal involvement, and extraintestinal manifestations are common. Crohn’s disease
is rarely curable and recurrence may be a lifelong problem, even after surgical resection.
In contrast, ulcerative colitis only affects the colon. The inflammatory process may
be limited to the rectum, extend proximally to include any contiguous segment, or
involve the entire colon. Ulcerative colitis may be cured by total colectomy.
2. Symptoms and signs of IBD include diarrhea, fecal incontinence, rectal bleeding,
abdominal pain, fatigue, fever, nausea, vomiting, arthralgia, abdominal tenderness,
palpable abdominal mass (usually inflamed loops of bowel) and perineal disease. You
may also have signs or laboratory findings indicating malnutrition, such as weight
loss, edema, anemia, hypoalbuminemia, hypokalemia, hypocalcemia, or hypomagnesemia.
3. IBD may be associated with significant extraintestinal manifestations in a variety
of body systems. These include, but are not limited to, involvement of the eye (for
example, uveitis, episcleritis, iritis); hepatobiliary disease (for example, gallstones,
primary sclerosing cholangitis); urologic disease (for example, kidney stones, obstructive
hydronephrosis); skin involvement (for example, erythema nodosum, pyoderma gangrenosum);
or non-destructive inflammatory arthritis. You may also have associated thromboembolic
disorders or vascular disease. These manifestations may not correlate with the severity
of your IBD. If your impairment does not meet any of the criteria of 5.06, we will
consider the effects of your extraintestinal manifestations in determining whether
you have an impairment(s) that meets or medically equals another listing, and we will
also consider the effects of your extraintestinal manifestations when we assess your
residual functional capacity.
4. Surgical diversion of the intestinal tract, including ileostomy and colostomy,
does not preclude any gainful activity if you are able to maintain adequate nutrition
and function of the stoma. However, if you are not able to maintain adequate nutrition,
we will evaluate your impairment under 5.08.
F. How do we evaluate short bowel syndrome (SBS)?
1. Short bowel syndrome (5.07) is a disorder that occurs when ischemic vascular insults (for example, volvulus),
trauma, or IBD complications require surgical resection of more than one-half of the
small intestine, resulting in the loss of intestinal absorptive surface and a state
of chronic malnutrition. The management of SBS requires long-term parenteral nutrition
via an indwelling central venous catheter (central line); the process is often referred
to as hyperalimentation or total
parenteral nutrition (TPN). Individuals with SBS can also feed orally, with variable amounts of nutrients
being absorbed through their remaining intestine. Over time, some of these individuals
can develop additional intestinal absorptive surface, and may ultimately be able to
be weaned off their parenteral nutrition.
2. Your impairment will continue to meet 5.07 as long as you remain dependent on daily
parenteral nutrition via a central venous catheter for most of your nutritional requirements.
Long-term complications of SBS and parenteral nutrition include central line infections
(with or without septicemia), thrombosis, hepatotoxicity, gallstones, and loss of
venous access sites. Intestinal transplantation is the only definitive treatment for
individuals with SBS who remain chronically dependent on parenteral nutrition.
3. To document SBS, we need a copy of the operative report of intestinal resection,
the summary of the hospitalization(s) including: Details of the surgical findings,
medically appropriate postoperative imaging studies that reflect the amount of your
residual small intestine, or if we cannot get one of these reports, other medical
reports that include details of the surgical findings. We also need medical documentation
that you are dependent on daily parenteral nutrition to provide most of your nutritional
G. How do we evaluate weight loss due to any digestive disorder?
1. In addition to the impairments specifically mentioned in these listings, other
digestive disorders, such as esophageal stricture, pancreatic insufficiency, and malabsorption,
may result in significant weight loss. We evaluate weight loss due to any digestive
disorder under 5.08 by using the Body Mass Index (BMI). We also provide a criterion
in 5.06B for lesser weight loss resulting from IBD.
2. BMI is the ratio of your weight to the square of your height. Calculation and interpretation
of the BMI are independent of gender in adults.
a. We calculate BMI using inches and pounds, meters and kilograms, or centimeters
and kilograms. We must have measurements of your weight and height without shoes for
b. We calculate BMI using one of the following formulas:
BMI = (
Weight in Pounds
(Height in Inches) x (Height in Inches)
) x 703
Weight in Kilograms
(Height in Meters) x (Height in Meters)
BMI = (
Weight in Kilograms
(Height in Centimeters) x (Height in Centimeters)
) x 10,000
H. What do we mean by the phrase “consider under a disability for 1
year”? We use the phrase “consider under a disability for 1
year” following a specific event in 5.02, 5.05A, and 5.09 to explain how long your impairment
can meet the requirements of those particular listings. This phrase does not refer
to the date on which your disability began, only to the date on which we must reevaluate
whether your impairment continues to meet a listing or is otherwise disabling. For
example, if you have received a liver transplant, you may have become disabled before
the transplant because of chronic liver disease. Therefore, we do not restrict our
determination of the onset of disability to the date of the specified event. We will
establish an onset date earlier than the date of the specified event if the evidence
in your case record supports such a finding.
I. How do we evaluate impairments that do not meet one of the digestive disorder
1. These listings are only examples of common digestive disorders that we consider
severe enough to prevent you from doing any gainful activity. If your impairment(s)
does not meet the criteria of any of these listings, we must also consider whether
you have an impairment(s) that satisfies the criteria of a listing in another body
system. For example, if you have hepatitis B or C and you are depressed, we will evaluate
your impairment under 12.04.
2. If you have a severe medically determinable impairment(s) that does not meet a
listing, we will determine whether your impairment(s) medically equals a listing.
(See §§404.1526 and 416.926.) If your impairment(s) does not meet or medically equal
a listing, you may or may not have the residual functional capacity to engage in substantial
gainful activity. In this situation, we will proceed to the fourth, and if necessary,
the fifth steps of the sequential evaluation process in §§404.1520 and 416.920. When
we decide whether you continue to be disabled, we use the rules in §§404.1594, 416.994,
and 416.994a as appropriate.
Category of Impairments, Digestive
5.02 Gastrointestinal hemorrhaging from any cause, requiring blood
transfusion (with or without hospitalization) of at least 2 units of blood per transfusion, and
occurring at least three times during a consecutive 6-month period. The transfusions
must be at least 30 days apart within the 6-month period. Consider under a disability
for 1 year following the last documented transfusion; thereafter, evaluate the residual
5.05 Chronic liver disease, with:
A. Hemorrhaging from esophageal, gastric, or ectopic varices or from portal hypertensive
gastropathy, demonstrated by endoscopy, x-ray, or other appropriate medically acceptable
imaging, resulting in hemodynamic instability as defined in 5.00D5, and requiring
hospitalization for transfusion of at least 2 units of blood. Consider under a disability
for 1 year following the last documented transfusion; thereafter, evaluate the residual
B. Ascites or hydrothorax not attributable to other causes, despite continuing treatment
as prescribed, present on at least two evaluations at least 60 days apart within a
consecutive 6-month period. Each evaluation must be documented by:
1. Paracentesis or thoracentesis; or
2. Appropriate medically acceptable imaging or physical examination and one of the
a. Serum albumin of 3.0 g/dL or less; or
b. International Normalized Ratio (INR) of at least 1.5.
C. Spontaneous bacterial peritonitis with peritoneal fluid containing an absolute
neutrophil count of at least 250 cells/mm3.
D. Hepatorenal syndrome as described in 5.00D8, with one of the following:
1. Serum creatinine elevation of at least 2 mg/dL; or
2. Oliguria with 24-hour urine output less than 500 mL; or
3. Sodium retention with urine sodium less than 10 mEq per liter.
E. Hepatopulmonary syndrome as described in 5.00D9, with:
1. Arterial oxygenation (PaO2) on room air of:
a. 60 mm Hg or less, at test sites less than 3000 feet above sea level, or
b. 55 mm Hg or less, at test sites from 3000 to 6000 feet, or
c. 50 mm Hg or less, at test sites above 6000 feet; or
2. Documentation of intrapulmonary arteriovenous shunting by contrast-enhanced echocardiography
or macroaggregated albumin lung perfusion scan.
F. Hepatic encephalopathy as described in 5.00D10, with 1 and either 2 or 3:
1. Documentation of abnormal behavior, cognitive dysfunction, changes in mental status,
or altered state of consciousness (for example, confusion, delirium, stupor, or coma),
present on at least two evaluations at least 60 days apart within a consecutive 6-month
2. History of transjugular intrahepatic portosystemic shunt (TIPS) or any surgical
portosystemic shunt; or
3. One of the following occurring on at least two evaluations at least 60 days apart
within the same consecutive 6-month period as in F1:
a. Asterixis or other fluctuating physical neurological abnormalities; or
b. Electroencephalogram (EEG) demonstrating triphasic slow wave activity; or
c. Serum albumin of 3.0 g/dL or less; or
d. International Normalized Ratio (INR) of 1.5 or greater.
G. End stage liver disease with SSA
CLD scores of 22 or greater calculated as described in 5.00D11. Consider under a disability
from at least the date of the first score.
5.06 Inflammatory bowel disease (IBD) documented by endoscopy, biopsy, appropriate medically acceptable imaging, or operative
A. Obstruction of stenotic areas (not adhesions) in the small intestine or colon with
proximal dilatation, confirmed by appropriate medically acceptable imaging or in surgery,
requiring hospitalization for intestinal decompression or for surgery, and occurring
on at least two occasions at least 60 days apart within a consecutive 6-month period;
B. Two of the following despite continuing treatment as prescribed and occurring within
the same consecutive 6-month period:
1. Anemia with hemoglobin of less than 10.0 g/dL, present on at least two evaluations
at least 60 days apart; or
2. Serum albumin of 3.0 g/dL or less, present on at least two evaluations at least
60 days apart; or
3. Clinically documented tender abdominal mass palpable on physical examination with
abdominal pain or cramping that is not completely controlled by prescribed narcotic
medication, present on at least two evaluations at least 60 days apart; or
4. Perineal disease with a draining abscess or fistula, with pain that is not completely
controlled by prescribed narcotic medication, present on at least two evaluations
at least 60 days apart; or
5. Involuntary weight loss of at least 10 percent from baseline, as computed in pounds,
kilograms, or BMI, present on at least two evaluations at least 60 days apart; or
6. Need for supplemental daily enteral nutrition via a gastrostomy or daily parenteral
nutrition via a central venous catheter.
5.07 Short bowel syndrome (SBS), due to surgical resection of more than one-half of the small intestine, with dependence
on daily parenteral nutrition via a central venous catheter (see 5.00F).
5.08 Weight loss due to any digestive disorder despite continuing treatment as prescribed, with BMI of less than 17.50 calculated
on at least two evaluations at least 60 days apart within a consecutive 6-month period.
5.09 Liver transplantation. Consider under a disability for 1 year following the date of transplantation; thereafter,
evaluate the residual impairment(s) (see 5.00D12 and 5.00H).