utions might include attention to working posture, tool redesign, task rotation, frequent r est breaks (see b p. 118, Ergonomics hazards: overview), and appropriate use of personal pr otective equipment (e.g. kneeling pads, padded clothing). Compensation Bursitis or subcutaneous cellulitis is prescribed for Industrial Injuries Disa blement Bene \201 t (A5, A6, A7) in manual workers who sustain severe or prolonged pressur e or friction over the hand, knee, or elbow. Relevant legislation Bursitis or subcutaneous cellulitis of the hand, knee, or elbow that i s attributable to manual work is reportable under RIDDOR. 09_Smedley_Chap09.indd 262 12/31/2012 8:56:42 PM 263 Chapter 10 Gastrointestinal and urinary tract disorders Hepatic angiosarcoma 264 Hepatic cirrhosis 266 Acute hepatotoxicity 268 Gastrointestinal ca ncers 270 Renal failure 272 Bladder cancer 274 10_Smedley_Chap10.indd 263 12/31/2012 8:58:36 PM CHAPTER 10 Gastrointestinal and urinary tract disorders 264 Hepatic angiosarcoma Epidemiology This otherwise very rare hepatic cancer occurs among work ers exposed to VCM and, less frequently, pesticide-exposed agricultural workers. Reactor (a utoclave) cleaners may be highly exposed to VCM, a genoto- xic carcinogen. When this associ ation was \201 rst recognized, VCM produc- tion workers showed 400 \227 expected inciden ce of hepatic angiosarcoma. However, owing to improved exposure control, the disease is now very rare in developed countries. Clinical features \200 Fatigue \200 Abdominal pain \200 Weight loss \200 Pyrexia \200 Jaundice \200 Ascites \200 Hepatosplenomegaly \200 Oesophageal varices. Causal exposure/industries \200 Vinyl chloride monomer production in the plastics industr y \200 Arsenic-containing pesticides used in vineyards. Clinical assessment/diagnosis \200 Thrombocytopenia, anemia, on full blood count \200 A bnormal liver function tests \200 CT/MRI scan: CT scan may show a multifocal tumor with hypo-attenuation; hyper-attenuation to liver suggests hemorrhage into the tumor \200 angiosarcoma is hypo-i ntense to normal liver on T 1 -weighted MRI images Liver biopsy: histology variable within a tumor. Vascular spaces, lined with tumor cells, may or may not be obvious. Prognosis Untreated, death occurs within months from hepatic encephalopathy or intra-abdomi nal bleeding. Health surveillance \200 Long latent interval between exposure and presentation \200 Li ver function tests (alanine aminotransferase (ALT), aspartate aminotransferase (AST)) identify hepatic impairment in VCM exposed workers Hepatic ultrasound has been used to identify pre-symptomatic angiosarcoma. Medical management Hepatic resection and/or chemotherapy may prolong life in those with an operable tumor. 10_Smedley_Chap10.indd 264 12/31/2012 8:58:36 PM HEPATIC ANGIOSARCOMA 265 Prevention Prevent by limiting exposure to VCM. Compensation Angiosarcoma of the liver is a prescribed disease (C24) for Industrial Injurie s Disablement Bene \201 t in those exposed to VCM in the manufacture of PVC. Relevant legislation \200 COSHH Schedule 5: monitor employee breathing zone VCM exposure \200 COSHH Schedule 6: annual health surveillance by HSE appointed doctor EH 40/2005 VCM, WEL 3ppm (8h TWA) \200 RIDDOR Regulations 1995: Angiosarcoma of the liver is a reportable disease among those exposed to VCM. 10_Smedley_Chap10.indd 265 12/31/2012 8:58:36 PM CHAPTER 10 Gastrointestinal and urinary tract disorders 266 Hepatic cirrhosis Epidemiology Common causes of liver cirrhosis worldwide include HBV, HCV, and alco- hol. Most cases of cirrhosis due to these agents are not work-related, but a sma ll proportion may be due to occupational exposure. Other rare causes of cirrhosis include w ork with halogenated hydrocarbons. Clinical features \200 Fatigue \200 Anorexia \200 Nausea \200 Spider naevi \200 J aundice \200 Pruritus \200 Ascites \200 Bleeding/bruising \200 Finger clubbing \200 Portal hypertension \200 Oesophageal varices \200 Hepatocellular cancer \200 He patic encephalopathy. Causal exposures/industries \200 Hepatitis B: \200 HCWs \200 Hepatitis C: \200 HCWs Alcohol: transportation industry \200 publicans and bar staff Organic solvents: carbon tetrachloride \200 1,1,1-trichloroethane. Clinical assessment/diagnosis \200 LFTs \200 Full blood count and clotting studies \200 Hepatitis B surface antigen \200 Hepatitis C antibody \200 Hepatic ultrasound \200 Liver biopsy. Prognosis Depends on the disease stage; once complications such as hepatic enceph- alopathy supervene, the prognosis is generally poor. A small proportion will develop primary carcin oma of the liver as a complication of cirrhosis. 10_Smedley_Chap10.indd 266 12/31/2012 8:58:36 PM HEPATIC CIRRHOSIS 267 Health surveillance \200 Biological monitoring of solvent-exposed workers using urinary metabolites or exhaled breath sampling may be indicated dependent on the risk assessment HCWs and others at risk of hepatitis B should be immunized and their immune status con \201 rmed by measuring hepatitis B surface antibody levels. Medical management \200 See b p. 152, Hepatitis B ; b p. 154, Hepatitis C \200 Abstinen ce from alcohol in alcoholic cirrhosis \200 Liver transplant: employment rates pre-operatively are lower for alcoholic liver disease than other indications for liver transplant. However, return to work rates post-tra nsplant are similar 45 \200\22370% of transplant recipients will return to work \200 poor physical functionin g and fatigue in \202 uence employment status post-transplant some centers employ living donor hepatic lobe transplants. Limited evidence suggests donors have a mean work absence of about 3mths. Prevention Preventing exposure to human blood and body \202 uids \200\224see b p. 104, Hu man tissue and body \202 uids. Compensation Liver \201 brosis is a prescribed disease for Industrial Injuries Disablemen t Bene \201 t in those who have been exposed to VCM in the manufacture of PVC (C24d). Cirr hosis is prescribed in those who have been exposed to chlorinated naphthalenes (C13). 10_Smedley_Chap10.indd 267 12/31/2012 8:58:36 PM CHAPTER 10 Gastrointestinal and urinary tract disorders 268 Acute hepatotoxicity A number of chemicals are recognized as causing acute hepatotoxicity, although some of them are no longer used in the way that once led to workers suffering adve rse effects. Hepatotoxicity due to occupational chemical exposure is now rarely reported in the UK. Epidemiology Common causes of hepatic insult \200 Alcohol \200 Metabolic syndrome \200 Drug reactions. Clinical features \200 Fatigue \200 Weight loss \200 Right upper quadrant abdominal p ain \200 Anorexia \200 Nausea \200 Jaundice \200 Impaired clotting. 2 Mild steatosi s may be asymptomatic Causal exposures/industries \200 Chemical industry including: carbon tetrachloride (CCl 4 ) \200 chlorinated napthalenes \200 dimethylformamide \200 chlordecone (kepone) \200 methylene dianiline \200 polychlorinated biphenyls \200 p hosphorus \200 trinitrotoluene Painting: 2-nitropropane Dry cleaning: perchloroethylene. Mechanism of hepatotoxicity Acute chemical hepatotoxicity may manifest itself in a number o f ways: \200 Steatosis (fatty liver): steatohepatitis if hepatic in \202 ammation present Acute hepatocellular injury (necrosis): direct toxicity \200 idiosyncratic reaction (e.g. halothane) Cholestasis (impaired bile \202 ow). Clinical assessment and diagnosis \200 Clinical examination looking for stigmata of chron ic liver disease or alcohol misuse 10_Smedley_Chap10.indd 268 12/31/2012 8:58:36 PM ACUTE HEPATOTOXICITY 269 Liver enzymes: alkaline phosphatase (AlkPhos) \200 alanine aminotransferase (ALT) \200 gamma glutamyl transpeptidase (GGT) Bilirubin \200 Carbohydrate de \201 cient transferrin (CDT): in suspected alcohol misuse \200 Albumin \200 Full blood count \200 Clotting screen \200\224prothrombin time \200 Hepatitis B surface antigen and core antibody \200 Hepatitis C antibodies \200 Li ver ultrasound +/ \200\223 biopsy: \201 ndings are dependent on the nature of the hepatic insult. Prognosis Dependent on the degree of hepatic injury but some cases will progress to cirrhos is. Health surveillance Biological monitoring may be indicated for some agents (e.g. solvents). Medical management \200 Withdraw from exposure to hepatotoxin \200 Lifestyle changes: abstinence from alcohol \200 weight loss if obese Review workplace risk assessment \200\224further controls may be required. Compensation Liver toxicity is prescribed for Industrial Injuries Disablement Bene \201 t in those who are exposed to carbon tetrachloride (C26(a)) or trichlo- romethane (C27). Relevant legislation Hepatotoxicity is reportable under RIDDOR where it is due to poisoning by any of the chemicals listed in Schedule 3, part 1. 10_Smedley_Chap10.indd 269 12/31/2012 8:58:36 PM CHAPTER 10 Gastrointestinal and urinary tract disorders 270 Gastrointestinal cancers Epidemiology Gastric cancer is the fourth most common cancer. \200 Adenocarcinoma is the most common gastric cancer \200 Gastric cancer is much more c ommon in Asia (Japan and China) than in Europe The annual incidence of gastric cancer is falling and is presently estimated at 870 000 cases/year worldwide Men are at twice the risk of gastric cancer as women \200 Occupational exposures have bee n linked to an increased risk of gastric cancer Most studies of pancreatic cancer have not found a link to occupation. Clinical features Gastric cancer \200 Weight loss \200 Abdominal pain \200 Dyspepsia \200 Dsyphagia \200 Anorexia. Causal exposures \200 Nitrosamines (gastric cancer) \200 Phenoxy herbicides Industries at risk \200 Industries at high risk: tin mining \200 steel works \200 carpentry Industries at increased risk: \200 chemical industry \200 coal mining \200 coke works \200 rubber industry \200 oil re \201 ning. Clinical assessment and diagnosis Investigation of gastric cancer includes endoscopy and bi opsy. CT scan may be used to identify metastases. Prognosis The prognosis of gastric cancer is generally poor as many patients present with a dvanced disease. Among those with operable disease 5yr survival is about 45%. Health surveillance No health surveillance has yet been proven to be bene \201 cial in occ upa- tional groups. Screening for gastric cancer in at-risk groups may be appro- priate, bu t further evaluation is necessary. 10_Smedley_Chap10.indd 270 12/31/2012 8:58:36 PM GASTROINTESTINAL CANCERS 271 Medical management and prevention The treatment of gastric cancer is partial or total gastr ectomy. Prevention relies on control of exposure to carcinogens. Relevant legislation COSHH Regulations 2002 (as amended). 10_Smedley_Chap10.indd 271 12/31/2012 8:58:36 PM CHAPTER 10 Gastrointestinal and urinary tract disorders 272 Renal failure Acute renal failure Occupational exposures that can cause acute renal failure (ARF) \200 Cadmium (see b p. 65, Cadmium) \200 Mercury (see b p. 72, Mercury) \200 O rganic solvents \200 Occupationally acquired infections (e.g. leptospirosis). Clinical fe atures of ARF \200 Oliguria or anuria \200 Nocturia \200 Ankle oedema \200 Fluid re tention \200 Impaired appetite \200 Tremor \200 Fatigue \200 Hypertension. Clinical assessment of renal failure \200 Urinalysis \200 Urea, electrolytes, and creat inine \200 Blood lipids \200 Full blood count \200 Renal ultrasound \200 IVP. Health surveillance Health surveillance for nephropathy is only likely to be undertaken in chronic exposure to cadmium. Cadmium workers should wear appropri- ate protective equipment and have regular biological monitoring of blood and urinary cadmium levels, with retinol b inding protein (RBP) if levels are persistently elevated. Compensation Kidney toxicity is prescribed (C26(b)) for Industrial Injuries Disablement Ben e \201 t in those who are exposed to carbon tetrachloride. 10_Smedley_Chap10.indd 272 12/31/2012 8:58:36 PM This page intentionally left blank CHAPTER 10 Gastrointestinal and urinary tract disorders 274 Bladder cancer Epidemiology \200 Bladder cancer is the seventh most common cancer in the UK \200 About 5 \200\22310% of bladder cancer in Europe may be due to occupational exposures Smoking is the major risk factor and may account for up to 80% of cases. However, where smo kers are exposed to carcinogens it is not possible to distinguish between occupational and non-occupational causes Bladder cancer is most common in the elderly and rare under age 40. Therefore, bladder canc er occurring at a young age is a red \202 ag for possible occupational etiology. Clinical features \200 Microscopic haematuria \200 Frank haematuria \200 Dysuria \200 Urinary frequency. Causal exposures \200 Polycyclic aromatic hydrocarbons (PAHs) \200 Aromatic amines: \200 benzidine \200 -napthylamine \200 ortho-toluidine \200 auramine \200 magen ta. MbOCA \200 Arsenic. Industries at risk \200 Historically, due to -napthylamine \200\224withdrawn in 1949: chemical industry (dyestuffs) \200 rubber industry Currently: coke works/coal gas works \200 printing \200 metal working \200 aluminum smelting (So derberg process) \200 painting \200 truck drivers \200 leather industry \200 hairdr essers. Individual susceptibility Family history of bladder cancer. Clinical assessment and diagnosis \200 Physical examination including rectal examination \200 Urinalysis 10_Smedley_Chap10.indd 274 12/31/2012 8:58:37 PM BLADDER CANCER 275 Intravenous pyelogram (IVP) \200 Cystoscopy and tumor biopsy \200 Urine cytology \200 Disease staging: CT scan, CXR, bone scan. Prognosis Five-year survival is 7 60% although this is in \202 uenced by the presence of m ultiple tumors, tumor bulk, and tumor stage. Health surveillance \200 Workers should remain subject to follow-up after exposure ceases \200 Once diagnosed, patients with super \201 cial bladder cancer are followed up with regular cystoscopy at 3 \200\2236-monthly intervals. Medical management \200 Transurethral resection +/ \200\223 chemotherapy, radiotherapy \200 Cystectomy for more extensive disease. Prevention \200 Improved control of chemical exposures has d incidence of occupational bladder cancer Most agents associated with bladder cancer are now banned in the UK (e.g. benzidine) Substitution of carcinogenic agents with less hazardous agents. Compensation \200 Primary neoplasm of the epithelial lining of the urinary tract is a prescribed disease (C23) for Industrial Injuries Disablement Bene \201 t in those who are exposed to: \200 aromatic amines \200 MbOCA for (cid:2)12mths \200 orthotoluidine, 4- chloro-2-methylaniline Coal tar pitch volatiles produced in aluminum smelting involving the Soderberg process for (cid:2)5yrs. Relevant legislation Bladder cancer is a reportable condition under RIDDOR 1995 where there has been work with any of the agents listed in Schedule 3. 10_Smedley_Chap10.indd 275 12/31/2012 8:58:37 PM This page intentionally left blank 277 Chapter 11 Eye disorders Eye injuries 278 Conjunctivitis and keratitis 280 Cataract 282 Retinal burns 284 11_Smedley_Chap11.indd 277 12/31/2012 9:03:33 PM CHAPTER 11 Eye disorders 278 Eye injuries Epidemiology Occupational eye injuries are common. Men suffer > 80% of eye inj uries with young men at highest risk. Those using power tools in engineering, construction, and farming are at particular risk. Causes Trauma Leading to: \200 Subtarsal foreign body \200 Corneal abrasion \200 Corn eal foreign body \200 Intra-ocular foreign body \200 Contusion: hyphaema \200 lens dislocation \200 retinal tear \200 commotio retinae \200 globe r upture. Non-ionizing radiation \200 Ultraviolet radiation B (UV-B) 280 \200\223315 nm \200 Arc welding: \200\230arc eye \200\231 or \200\230welder \200\231s \202 ash \200\231 \200 Lasers \200 High-intensity discharge lamps (HIDL). Chemicals \200 Acids \200 Alkalis. Industries/occupations at greatest risk \200 Construction \200 Agriculture \200 Metal working, especially welding, grinding, shot-blasting \200 Woodworking \200 Transportati on. Prevention \200 Safe systems of work \200 Machinery guards, interlocks \200 Dust supp ression \200 Enforce use of appropriate eye protection: goggles, glasses, masks \200 In formation, instruction, and training. Clinical assessment and diagnosis \200 Visual inspection: evert eyelids to identify sub-t arsal foreign body \200 Fundoscopy \200 Slit-lamp microscopy \200 Fluorescein stainin g for suspected corneal abrasions: \202 uoresce under blue light 11_Smedley_Chap11.indd 278 12/31/2012 9:03:33 PM EYE INJURIES 279 Test visual acuity: near and distance vision \200 X-ray globe to identify retained foreig n body. Medical management \200 Chemical exposures: irrigate eye thoroughly using normal saline o r sterile water. Exposure to strong alkali or acid can be sight threatening (see b pp. 792, 793, General principles, Management of chemical exposures to the eye) It is important that appropriate \201 rst aid facilities including eye-wash stations are present in high-risk work areas. Relevant legislation Temporary or permanent loss of sight, penetrating eye injury, chemical or hot metal burns to the eye are all reportable under RIDDOR as major injuries. 11_Smedley_Chap11.indd 279 12/31/2012 9:03:33 PM CHAPTER 11 Eye disorders 280 Conjunctivitis and keratitis Conjunctivitis may be due to exposure to physical, chemical, o r biological agents (e.g. bacteria, viruses). Epidemiology Data from an American workers compensation scheme found: \200 Annual inciden ce of allergic conjunctivitis, 731/100,000 workers \200 Annual incidence of keratitis, 72 3/100,000 workers. Clinical features \200 Severe photophobia \200 Lacrimation \200 Conjunctival injectio n \200 Headache. Causal industries and exposures \200 Arc welding: intense UV-B light from the arc \200 Inappropriate use of UV-C lights instead of the required UV-A lights in electric \202 y k illers used in food industry and commercial kitchens: such incidents may affect several wor kers who develop keratitis and facial erythema. Diagnosis is often delayed by several month s Acid mists Hydrogen sulfide (H 2 S) conjunctivitis: occurs at 750 ppm H 2 S (see b p. 99, Hydrogen sulfide and b p. 800, Hydrogen sulfide poisoning) Vanadium pentoxide \200 Some organic solvents Allergens: e.g. laboratory animals such as rats and mice, in association with rhinitis: rhinoconjunctivitis \200 Ophthalmology: expo sure when examining infected patients may lead to the clinician developing bacterial or viral conjunctivitis \200 Sharing microscopes: e .g. in electronics factories, may lead to outbreaks of infectious conjunctivitis. Diagnosis Welder \200\231s \202 ash History of unprotected eye exposure to arc welding \200 Symptoms develop 6 \200\22312h post-exposure: severe photophobia \200 lacrimation \200 headache The typical patient is an apprentice who, through ignorance or carelessness, is close to a welder when an arc is struck. Allergic conjunctivitis Based on history of exposure to allergen and i speci \201 c IgE. I nfectious conjunctivitis Diagnosis by swabs for microscopy, culture, and sensitivity. 11_Smedley_Chap11.indd 280 12/31/2012 9:03:33 PM CONJUNCTIVITIS AND KERATITIS 281 Prognosis Welder \200\231s \202 ash: full recovery. Health surveillance None appropriate. Medical management \200 \200\230Arc eye \200\231 (kerato-conjunctivitis) is treated with topical local anesthetic drops and a mydriatic Bacterial conjunctivitis is treated with topical antibiotics \200 There is no consensus a s to whether ophthalmologists should work when suffering from conjunctivitis, given the pot ential to cross-infect patients. Relevant legislation An injury at work that caused conjunctivitis, and was associated with 7 days \200\231 work loss or temporary loss of sight, would be reportable under RIDDOR. 11_Smedley_Chap11.indd 281 12/31/2012 9:03:33 PM CHAPTER 11 Eye disorders 282 Cataract Epidemiology \200 Worldwide cataract is the most common cause of blindness \200 A number of occupational exposures contribute to this burden \200 Penetrating eye injur ies are most common in young men and may lead to traumatic cataract. Causes \200 Non-ionizing radiation: UV-B (cortical cataract) \200 IR Lasers (medical, industrial) \200 Electrocution \200 Penetrating eye injuries \200 In organic lead \200 Chemicals, e.g. trinitrotoluene, ethylene oxide, methyl isocyanate. Industries at risk \200 Metal foundries \200 Arc welding \200 Glass blowing \200 Pr inting with use of HIDL. Investigations In the event of a disease cluster, an occupational hygiene survey may be und ertaken to monitor workplace exposures. Health surveillance There is no regulatory requirement for health surveillance. Medical man agement and prevention \200 Engineering controls: interlocks \200 shielding Administrative controls: information, instruction, and training \200 access controls Personal protective equipment: safety goggles. Compensation Cataract is a prescribed disease (A2) for Industrial Injuries Disablement Bene \201 t in those who have frequent or prolonged exposure to radiation from red-hot or whit e-hot material. Relevant legislation Cataract due to electromagnetic radiation (including radiant heat) is reportable under RIDDOR. 11_Smedley_Chap11.indd 282 12/31/2012 9:03:33 PM This page intentionally left blank CHAPTER 11 Eye disorders 284 Retinal burns Epidemiology Retinal burns may occur in the workplace because of the use of h igh-power lasers (the acronym laser stands for light ampli \201 cation by the stimulated e mis- sion of radiation) or, less commonly, arc welding equipment. Intense expo- sure to sol ar radiation (e.g. on snow \201 elds) may also lead to retinal burns. Lasers are very widely used (e.g. consumer electronics, telecommunica- tions, engineering). However, estimates suggest there are <15 occupational laser injuries per year worldwide, m ostly due to exposure to powerful Q-switched industrial or military lasers (see b p.28, Non -ionizing radia- tion 3: laser). Lasers can cause photomechanical and photochemical eye injuries, as well as retinal burns. Most laser incidents involve damage to the macula; an affected worker will be immediately a ware of altered vision and will present to an optician or doctor. Clinical features \200 Blurred vision \200 Usually painless. Causal exposures/industries \200 Research, e.g. nuclear physics \200 Military: laser range \201 nders \200 target designators Health care: ophthalmology. Clinical assessment and diagnosis \200 Visual acuity: Snellen chart \200 Test visual \201 elds \200 Fundoscopy \200 Retinal photography \200 Fluorescein angiography. Prognosis \200 Retinal damage due to lasers is permanent \200 Outcome depends on the lo cation and size of the burn \200 Foveal burns may have a severe effect on visual acuity. Health surveillance In the UK, HSE does not currently recommend routine health surveillance for laser workers. Medical management Refer on to an ophthalmologist with expertise in the management of ret- inal burns for assessment. 11_Smedley_Chap11.indd 284 12/31/2012 9:03:34 PM RETINAL BURNS 285 Relevant legislation \200 Maximum permissible exposure values (MPEs) for lasers are speci \201 ed by the International Commission on Non-ionizing Radiation Protection, and are set at levels where no harm is likely to occur 1 Risk assessments under the Management of Health and Saf ety at Work Regulations 1999 should also consider non-beam hazards such as the use of high- voltage power sources. The Private and Voluntary Health Care (England) Regulations 2001 govern the use of lasers i n the private health sector in England. 11_Smedley_Chap11.indd 285 12/31/2012 9:03:34 PM