# **G**

GALLBLADDER DISEASE

The gallbladder is a pear-shaped organ located on the under surface of
the right lobe of the liver where it acts as a reservoir for bile. The
bile is periodically released into the common bile duct, which carries
it into the upper bowel to aid digestion. The gallbladder and biliary
ducts are a common site of acute or chronic inflammation and stone
formation. Since an association has been noted statistically between
gallbladder disease and coronary artery disease, the possibility of a
gallbladder disorder masking some coronary involvement warrants
consideration. The common disorders of the gallbladder are:

**Cholelithiasis** -- The presence of biliary concentrations that take
the form of calculi, or \"stones.\" When they do not produce symptoms
and are discovered accidentally on x-ray examination, they are known as
\"silent stones.\"

**Choledocholithiasis** -- The presence of calculi in the common bile
duct. In this location the obstruction usually causes jaundice.

**Cholangitis** -- The inflammation of a biliary duct. Some degree of
cholangitis is present in most gallbladder disorders.

**Biliary or hepatic colic** -- The sharp cramp-like pain caused by the
movement of a stone in one of the biliary ducts.

**Cholecystitis** -- The inflammation of the gallbladder that may also
involve the biliary ducts. It is usually caused by stones but may occur
without them.

**Acute cholecystitis** -- Characterized by severe pain and tenderness
in the upper abdomen, vomiting, and frequently fever.

**Chronic cholecystitis** -- A chronic inflammation of the gallbladder
with repeated attacks of pain and tenderness, excessive gas and
belching, and poor tolerance of fatty foods.

**Cholecystectomy** -- The removal of the gallbladder.

**Cholecystostomy** -- Opening gallbladder or the surgical drainage or
removal of stones. This procedure is used instead of cholecystectomy to
relieve symptoms in patients who might be poor risks for surgery. It is,
therefore, advisable to rule out the presence of other impairments in
applicants who have this history.

**Choledochotomy** -- The cutting into the common bile duct for
exploration or removal of a stone.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  -------------------------------- ---------------------- --------------------- ---------------------
  Cholecystitis, cholelithiasis    One attack without     One attack [with      More than one attack
  (gallstones), biliary or hepatic [stones]{.underline}   stones]{.underline}   with or [without
  colic, cholangitis                                                            stones]{.underline}

  Present with symptoms            50                     100                   200

  No symptoms within 1 years       30                     50                    100

  No symptoms within 2 years       15                     35                    75

  No symptoms within 3 years       0                      25                    50

  No symptoms within 4 years       0                      10                    20

  No symptoms within 5 years       0                      0                     0
  -------------------------------- ---------------------- --------------------- ---------------------

+-----------------------------------------------------+----------------+
| Chronic Cholecystitis                               |                |
+-----------------------------------------------------+----------------+
| No treatment recommended                            | 0              |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| Silent stone -- discovered accidentally, without    | 0              |
| symptoms                                            |                |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| "Sluggish" or "non-functioning" gallbladder         | 0              |
| (Distinguish from acute and chronic cholecystitis   |                |
| as described above)                                 |                |
+-----------------------------------------------------+----------------+
| X-ray negative for stones, no other complications   | 0              |
| and no further symptoms                             |                |
+-----------------------------------------------------+----------------+
| With occasional mild symptoms but no disability     | 0              |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| Choledocholithiasis                                 | Rate as more   |
|                                                     | than one       |
|                                                     | attack or      |
|                                                     | chronic        |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| Cholecystostomy -- surgical drainage of gallbladder |                |
+-----------------------------------------------------+----------------+
| Within 3 months of recovery                         | 75             |
+-----------------------------------------------------+----------------+
| Within 3-12 months of recovery                      | 50             |
+-----------------------------------------------------+----------------+
| Within 2^nd^ year of recovery                       | 30             |
+-----------------------------------------------------+----------------+
| Within 3^rd^ year of recovery                       | 20             |
+-----------------------------------------------------+----------------+
| Within 4^th^ year of recovery                       | 10             |
+-----------------------------------------------------+----------------+
| After 4 years                                       | 0              |
+-----------------------------------------------------+----------------+
| With complications                                  | Add 25         |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| Cholecystectomy -- removal of gallbladder           |                |
+-----------------------------------------------------+----------------+
| Without choleochotomy                               |                |
+-----------------------------------------------------+----------------+
| > With or without stones found at time of operation | 0              |
| > and returned to normal duties                     |                |
+-----------------------------------------------------+----------------+
| With complications or still symptomatic             | Add 25         |
+-----------------------------------------------------+----------------+
| With choledochotomy                                 |                |
+-----------------------------------------------------+----------------+
| Not fully recovered or with mild digestive symptoms | Add 25         |
| requiringonly dietetic care                         |                |
+-----------------------------------------------------+----------------+
| With more than one operation or more than mild      | Add 200        |
| continuing symptoms following surgery               |                |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| Lithotripsy                                         |                |
+-----------------------------------------------------+----------------+
| Recurrent                                           | Rate as        |
|                                                     | Cholecystitis  |
+-----------------------------------------------------+----------------+
| Otherwise                                           | 0              |
+-----------------------------------------------------+----------------+

**GANGLION**

A ganglion is a benign cyst in the region of a tendon sheath or joint
capsule, usually on the back of the hand or on the foot.

  ----------------------------------------------------- -----------------
  With definite diagnosis                               0

  ----------------------------------------------------- -----------------

GANGRENE

Gangrene is a term that means \"death of soft tissue.\" It usually
results from impaired circulation due to injury or disease of the blood
vessels in the affected part. It may be due to infection (gas gangrene).

**Underwriting Requirements**

An APS (VA Form 29-8158) will be required if not adequately described.
Rule out diabetes and arteriosclerosis as cause.

  -------------------------------------------- --------------------------
  Unoperated                                   

  Within 3 months                              300

  3 months after recovery and no residuals     0

  Operated (amputation)                        Apply rating for
                                               Amputations

  Others -- including diabetes and             RFC and add rating for
  arteriosclerosis                             Amputations

  Others -- from gas bacillus infection (if    0 and add rating for
  recovered)                                   Amputation or deformity
  -------------------------------------------- --------------------------

**GASTRIC STAPLING, GASTROPLASTY, GASTRIC PLICATION**

A wide variety of surgical procedures have been attempted to treat
obesity, none of which has been entirely satisfactory. These include
insertion of balloons into the stomach, intestinal and gastric bypass
procedures and procedures which restrict the amount of food which can be
ingested, such as gastric stapling.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  -------------------------------------------- --------------------------
  Weight stabilized for 6 months, liver        Apply debits for Build
  function tests normal                        

  Weight not stabilized                        Refer to Section Chief

  Combination of overweight and other factors  Sum debits
  -------------------------------------------- --------------------------

GAUCHER\'S DISEASE

Gaucher\'s disease is a familiar disorder of the cerebroside metabolism
characterized by abnormal large reticuloendothelial cells whose
proliferation is responsible for the enlargement of the spleen, liver
and intrathoracic and intra-abdominal lymph nodes, and in turn, changes
in the bone marrow. There is osteoporosis with compression of vertebrae,
head of femur, pelvis, tibiae and humeri with deformity and fractures.
The hepatic function is normal. With splenomegaly there is usually, at
some time, hypersplenism with memolytic anemia, leukopenia,
thrombocytopenia, patchy brown pigment of skin especially over anterior
surfaces of legs and malar region and pingueculus of the cornea.

There are two forms of Gaucher\'s disease: (1) acute or infantile, which
is severe, of short duration and fatal; (2) chronic or adult type, which
may affect individuals who may lead a nearly unhandicapped life,
especially after splenectomy.

Splenectomy (in hypersplenism) is of great value in correcting the
hemolytic anemia, leukopenia and thrombocytopenia caused by the abnormal
splenic function but, otherwise, apparently does not influence the
course of the disease. Death is usually due to an intercurrent infection
but if the individuals survive they become cachetic. There is no
satisfactory course of treatment.

Diagnosis most easily made by marrow aspiration; biopsy of liver or
spleen is also diagnostic.

Underwriting Requirements

An APS (VA Form 29-8158) is required.

  --------------------------------------------------- -------------------
  Without splenectomy                                 

  Mild                                                500-300

  Moderate                                            1000-500

  Severe                                              3000-1000

  With splenectomy                                    

  Mild                                                150

  Moderate                                            300

  Severe                                              1000-500
  --------------------------------------------------- -------------------

GIANT CELL TUMOR OF THE BONE

Giant cell tumor of the bone is a benign growth usually occurring in the
long bones, slow growing, and containing characteristic cells, called
giant cells, which give it its name. Although it is considered a benign
tumor when single, very rarely it may become malignant.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ----------------------------------------------- -----------------------
  Benign                                          0

  Malignant                                       See Tumor Rating Chart
                                                  A -- Giant Cell Sarcoma
  ----------------------------------------------- -----------------------

**GOUT**

Excess uric acid in the blood (hyperuricemia) usually causes no
symptoms. Occasionally uric acid crystals are deposited in joint spaces
and cause a painful arthritic condition known as gout. Crystal
deposition may also cause kidney stones and other kidney diseases.
Medical treatment is usually effective in preventing attacks of gout and
renal disease.

Pseudogout resembles regular gout in its manifestations, but is caused
by a different chemical deposited in the joints.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  -------------------------------------------------- --------------------
  Hyperuricemia, asymptomatic                        0

  Gout and pseudogout                                

  Occasional mild attacks, uric acid level           0
  controlled by medication (i.e. less than 10 mg%)   

  Otherwise                                          

  Within 1 year of last attack                       75

  Within 2^nd^ year                                  50

  After 2 years                                      0
  -------------------------------------------------- --------------------

**GUILLAIN-BARRE SYNDROME**

This disorder is an acute post-infective state of the spinal and
peripheral nerves and is probably caused by an altered immune response
to an otherwise innocuous viral illness. It sometimes requires prolonged
convalescence and may result in residual paralysis.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------ ----------------------------
  Without residual impairment                0

  With residual impairment                   Rate as Poliomyelitis
  ------------------------------------------ ----------------------------

GYNECOLOGIC DISORDERS (Females)

The uterus, fallopian tubes, and ovaries are contained in the lower part
of the abdominal cavity or pelvis. The treatment of diseases and
disorders of these organs belong to the branch of medical practice known
as gynecology. Malignancy is the chief concern in underwriting disorders
of the uterus, vagina, fallopian tubes and ovaries. This possibility
increases with age.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

+---------------------------------------------------+------------------+
| Fibroid tumors                                    |                  |
+---------------------------------------------------+------------------+
| Present                                           |                  |
+---------------------------------------------------+------------------+
| Small, non-progressive                            | 0                |
+---------------------------------------------------+------------------+
| Others                                            | Refer to Section |
|                                                   | Chief            |
|                                                   |                  |
|                                                   | R-30             |
+---------------------------------------------------+------------------+
| History                                           |                  |
+---------------------------------------------------+------------------+
| Surgical removal by hysterectomy or by            | 0                |
| fibroidectomy                                     |                  |
+---------------------------------------------------+------------------+
| Pathology report benign                           | 0                |
+---------------------------------------------------+------------------+
| Otherwise                                         | See Tumor Rating |
|                                                   | Chart C          |
+---------------------------------------------------+------------------+
|                                                   |                  |
+---------------------------------------------------+------------------+
| Hydatidiform Mole                                 |                  |
+---------------------------------------------------+------------------+
| Uterus removed, mole benign                       | 0                |
+---------------------------------------------------+------------------+
| Others                                            | See Tumor Rating |
|                                                   | Chart A --       |
|                                                   | Echinococcus     |
|                                                   | (Hydatid Cyst)   |
+---------------------------------------------------+------------------+
|                                                   |                  |
+---------------------------------------------------+------------------+
| Ovarian cysts and tumors                          |                  |
+---------------------------------------------------+------------------+
| Simple cyst in premenopausal female present less  | 0                |
| than 2 months diagnosed by AP or ultrasound as    |                  |
| functional or corpus luteum cyst                  |                  |
+---------------------------------------------------+------------------+
| Others                                            | R                |
+---------------------------------------------------+------------------+
| Surgically removed, benign                        | 0                |
+---------------------------------------------------+------------------+
| Surgically removed, malignant                     | See Tumor Rating |
|                                                   | Chart A          |
+---------------------------------------------------+------------------+

**[Menstrual disorders]{.underline}**

**Amenorrhea** -- absence of menses. Females with eating disorders and
those who exercise excessively may have amenorrhea.

**Dysmenorrhea** -- painful menstruation. Endometriosis is one cause.

**Menorrhagia** -- excessive uterine bleeding occurring at regular
intervals of menstruation. Endometriosis is one cause.

**Metrorrhagia** -- uterine bleeding occurring at irregular intervals.

**Menometrorrhagia** -- excessive uterine bleeding occurring both during
menses and at irregular intervals.

**Postmenopausal bleeding** -- vaginal bleeding after menopause. Common
in women on hormone replacement therapy. Often due to benign cause but
cancer must always be ruled out.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------------- ---------------
  Menstrual disorders                                     

  Cause known                                             RFC

  Cause unknown                                           

  Malignancy ruled out                                    0

  Others                                                  R
  ------------------------------------------------------- ---------------

[Pelvic Inflammatory Disease]{.underline}

Pelvic Inflammatory Disease is an infection of the fallopian tubes but
also may be used to describe vervicitis, endometritis or oophoritis.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------------- ---------------
  Pelvic Inflammatory Disease                             

  Single attack with recovery                             0

  Recurrent attacks                                       

  Within 1 year                                           20

  Within 2 years                                          10

  After 2 years                                           0

  Cured by operation and recovered                        0
  ------------------------------------------------------- ---------------

[Papanicolaou's Stain]{.underline}

The "pap smear" is a screening test which can indicate abnormalities of
the organ (cervix, uterus) from which it was obtained. It may be
reported as Class I through V, or as showing varying degrees of
dysplasia, called Cervical Interaepethelial Neoplasia or CIN.

Classification:

+--------+------------------------------+-----------------------------+
|        | [Pap Smear]{.underline}      | [CIN]{.underline}           |
+--------+------------------------------+-----------------------------+
| Class  | Normal                       |                             |
| I      |                              |                             |
+--------+------------------------------+-----------------------------+
| Class  | Atypical cells               |                             |
| II     |                              |                             |
+--------+------------------------------+-----------------------------+
| Class  | Abnormal cells               | CIN 1 Mild Dysplasia        |
| III    |                              |                             |
|        |                              | CIN 2 Moderate Dysplasia    |
+--------+------------------------------+-----------------------------+
| Class  | Abnormal cells, cancer in    | CIN 3 Severe Dysplasia      |
| IV     | situ                         |                             |
+--------+------------------------------+-----------------------------+
| Class  | Abnormal, Invasive cancer    |                             |
| V      |                              |                             |
+--------+------------------------------+-----------------------------+

+----------------------------------------+-----------------------------+
| Class I or II                          | 0                           |
+----------------------------------------+-----------------------------+
| Class III                              |                             |
+----------------------------------------+-----------------------------+
| Not evaluated                          | Refer to Section Chief      |
+----------------------------------------+-----------------------------+
| Treated and follow-up smears are Class | 0                           |
| I or II                                |                             |
+----------------------------------------+-----------------------------+
| Others                                 | Refer to Section Chief      |
+----------------------------------------+-----------------------------+
| Class IV                               | See Tumor Rating Chart A -- |
|                                        |                             |
|                                        | Cervix uteri in situ or     |
|                                        | Uterus                      |
+----------------------------------------+-----------------------------+
| Class V                                | See Tumor Rating Chart A -- |
|                                        |                             |
|                                        | Cervix uteri or Uterus      |
+----------------------------------------+-----------------------------+

[Pregnancy]{.underline}

  ------------------------------------------------------ ----------------
  Currently pregnant                                     0

  History of pregnancy terminating in abortion           

  Spontaneous or elective                                0

  Therapeutic                                            RFC
  ------------------------------------------------------ ----------------

**[Toxemia of Pregnancy]{.underline}**

Toxemia of pregnancy is a series of abnormal conditions occurring during
pregnancy, principally caused by disturbed metabolism. The most common
symptoms are headaches, elevated blood pressure, albuminuria, and edema
(swelling) of the legs. Most severe disturbances in late pregnancy may
lead to eclampsia, characterized by intermittent convulsions and coma.
The kidneys and liver may suffer permanent damage. Recurrences during
subsequent pregnancies are common.

**Underwriting Requirements**

An APS (VA 29-8158) is required.

  ----------------------------------------------------- -----------------
  Mild or moderately severe, or pre-eclampsia, no       0
  convulsions, with otherwise normal full term delivery 

  Severe toxemia or eclampsia, with or without          See Pregnancy
  caesarean operation, or requiring termination of      
  pregnancy; with subsequent normal pregnancy           

  With sterilization or passed menopause                0
  ----------------------------------------------------- -----------------

GYNECOMASTIA

Gynecomastia is a condition in males in which the mammary glands become
excessive in

size. This is not considered abnormal during puberty. However, where it
becomes evident after maturity, the underlying cause should be sought.

  ------------------------------------------------------- ---------------
  Present, small or medium size                           0

  Large                                                   25

  After recovery                                          0
  ------------------------------------------------------- ---------------