Diagnostic Assessment — Acute Enteritis
Example 1 of 1 · fictitious patient
Diagnostic Assessment Acute Enteritis BOP Code: N/A (there is no Statement of Principles for this condition) RH Code: N/A
ADF History
The veteran, date of birth [withheld], Australian Army, Transport Driver, 16 January 1979 to 1 November 1985
Occupational History
Australian Army service aboard ships involves communal cooking and eating facilities, exposure to varying water quality, and limited sanitation in some operational settings.
Gastroenteritis is a common infectious disease in the service environment
History
The veteran had multiple episodes of gastroenteritis during ADF service.
The earliest documented episode was on 29 January 1981, when he had acute viral gastroenteritis with diarrhoea, vomiting and abdominal colic after seafood; further episodes followed on 16 December 1981 (diarrhoea with an upper respiratory infection), 10 and 25 January 1982 (vomiting and diarrhoea, treated with pethidine and then tinidazole) and 19 April 1982 (vomiting and diarrhoea after seafood, ?food poisoning).
On 5 October 1982 he was seen in a logistics unit at midnight with vomiting, diarrhoea and abdominal pain.
A further episode occurred on 25 November 1982 with vomiting and diarrhoea, temperature 37°C, and a mildly raised white cell count (WCC 12.9).
A further episode occurred on 25 October 1983 with nausea and abdominal cramp, documented as viral gastroenteritis.
A further episode required admission to RANH a logistics unit from 16 to 2 August 1984 with watery, explosive diarrhoea for five days that had not been controlled by diet restriction and Imodium.
There was bilateral lower abdominal tenderness, more marked over the descending colon; the FBC was normal and stool cultures (x 3) showed no pathogens.
He was commenced on metronidazole empirically, with a decrease in abdominal discomfort and tenderness, and was discharged on Flagyl with a final diagnosis of acute enteritis
Timeline
29 Jan 1981 — Sudden onset of diarrhoea, vomiting and abdominal colic the previous night after seafood; temperature 37.2°C, tender left iliac fossa; IM Stemetil and Lomotil; off duty 2 days (the treating doctor, a logistics unit). "Acute viral gastro-enteritis" 16 Dec 1981 — URTI with diarrhoea; Septrin Forte, Lomotil and Stemetil; off duty 2 days. "URTI.
Diarrhoea" 22 Jan 1982 — Abdominal pain for 2 days and vomiting all day; pethidine 100 mg and Maxolon; unfit.
On 25 Jan 1982 vomiting and diarrhoea five times a day, treated with Fasigyn (tinidazole) 2 g. "Gastroenteritis" 19 Apr 1982 — Vomiting and diarrhoea after seafood on Friday night; temperature 36.5°C; advised on diet, antinauseant (a logistics unit). "Gastritis (Food? Poisoning)" 05 Oct 1982 — ABSR the veteran was seen at midnight with vomiting, diarrhoea, and abdominal pain.
Temperature about 36.5°C.
He had been given Stemetil initially which stopped the vomiting, but diarrhoea and abdominal pain persisted.
Pulse 80.
Abdomen soft with mild generalised tenderness.
Adequate oral intake.
Treated with Perolyl (gastro medication), Imodium stat, and clear fluids. "Viral gastroenteritis" 25 Nov 1982 — ABSR the veteran presented with vomiting x2 and diarrhoea x2 overnight.
Temperature 37°C.
FBC performed showing WCC 12.9 (mildly raised).
Abdomen soft. "Gastroenteritis" 27 Oct 1983 — ABSR the veteran was sick at shore on 25 October 1983 with nausea and vague abdominal cramp
Symptoms
Consistent with recent viral illness.
Excused duty 2 days. "Viral gastroenteritis" 31 Oct 1983 — ABSR the veteran presented with abdominal cramp, much improved, fit to return to work. "Abdominal cramp" 30 Jul 1984 — ABSR the veteran was admitted to RANH a logistics unit with watery, explosive diarrhoea for the past five days, uncontrolled by diet restriction and Imodium.
Some bilateral lower abdominal tenderness, more marked over the descending colon.
FBC normal.
Stool cultures x 3 showed no pathogens; faecal occult blood, wet preparation and ova, cysts and parasites were nil.
Commenced on metronidazole empirically, with decrease in abdominal discomfort and tenderness.
Discharged on 02 Aug 1984 on Flagyl 400mg tds for 7 days. "Acute enteritis"
Symptoms
Vomiting, diarrhoea, abdominal pain, nausea, and general malaise across multiple episodes during service, including five days of watery, explosive diarrhoea with lower abdominal tenderness requiring hospital admission in July 1984
Imaging
No imaging related to this condition
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Acute Enteritis / Gastroenteritis (ICD-10: A09.9).
Multiple episodes of acute gastroenteritis were documented during ADF service from January 1981 to July 1984; no causative organism was identified
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? 29 January 1981 (first documented episode) [CHART REVIEW document] When did the veteran first present to a health / medical provider for this condition? 29 January 1981 When was the condition confirmed / formally diagnosed? 29 January 1981 (acute viral gastroenteritis) [CHART REVIEW document] When did the veteran first present to you (or your practice) for this condition? 28 May 2020
3. How was this diagnosis confirmed?
Clinical diagnosis based on symptoms of vomiting, diarrhoea, and abdominal pain [ [CHART REVIEW document], pages 71, 63, 62, 55, 50].
FBC on 25 November 1982 showed a mildly raised WCC of 12.9 [CHART REVIEW document].
Acute enteritis was the final diagnosis for the admission to RANH a logistics unit from 16 to 2 August 1984, with bilateral lower abdominal tenderness, a normal FBC and stool cultures (x 3) showing no pathogens [ [CHART REVIEW document], pages 101 102]
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 15 April 1999 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
There is no Statement of Principles for acute enteritis or gastroenteritis of unspecified cause, and because no causative organism was identified in any episode, no other Statement of Principles can be applied by analogy.
The question under the DRCA is whether the enteritis arose out of, or in the course of, the veteran's service, or was contributed to by his service to a significant degree.
Plausible Links to Service the veteran's service medical record documents repeated episodes of acute gastroenteritis, of which the July 1984 admission was the most prolonged.
On 29 January 1981, while he was serving in a logistics unit at a logistics unit, he had acute viral gastroenteritis with sudden diarrhoea, vomiting and abdominal colic after eating seafood; on 16 December 1981, diarrhoea with an upper respiratory tract infection; on 10 and 25 January 1982, gastroenteritis with vomiting all day and diarrhoea five times a day, treated with pethidine and then tinidazole; on 19 April 1982, vomiting and diarrhoea after seafood, recorded as possible food poisoning; on 5 October 1982, viral gastroenteritis treated in a logistics unit; on 25 November 1982, vomiting and diarrhoea with a mildly raised white cell count of 12.9, treated in the sick bay of a logistics unit; and on 25 October 1983, viral gastroenteritis for which he was admitted to Prince Henry Hospital.
In mid-July 1984 he developed severe watery diarrhoea and was admitted to RANH a logistics unit from 16 to 2 August 1984 with acute enteritis; three stool cultures and examination for ova, cysts and parasites showed no pathogen, and he improved on empirical metronidazole.
No organism was identified in any episode, and later investigation of rectal bleeding was reported as normal.
Acute infective enteritis is caused by viruses, bacteria and parasites carried in contaminated food and water or passed from person to person, and it spreads readily where people share catering, water supplies, sleeping quarters and ablutions.
The veteran's naval service placed him in those settings: ships and naval establishments with communal galleys and messes, ships' water supplies, and shared living quarters, toilets and showers; service in tropical a logistics unit from 1980 to 1982; and service in a logistics unit during the deployment referred to by the Medical Board of 3 February 1983, when he was taking malaria prophylaxis (2 February to 21 December 1982), which indicates that the ship's program took it to a region where malaria occurs, although the destination is not recorded.
The episodes of 5 October 1982 and 25 November 1982 were treated by the medical staff of a logistics unit, and those of January 1982 and July 1984 were treated empirically with tinidazole and metronidazole, agents directed at protozoal and other organisms acquired from contaminated food or water.
Not every episode can be tied to a service source.
The episodes of 29 January 1981 and 19 April 1982 followed seafood meals whose source is not recorded; in October 1983 he was ill at home at the same time as his wife, and in July 1984 the discharge summary noted that his wife had recently been an in-patient with a "bowel condition", so a household source is possible for the 1984 illnesses.
Section 5B of the DRCA allows activities unrelated to employment to be weighed against the nature of the employment.
However, the absence of a record of where a meal was eaten does not show that it was not provided through service, and the recurrence of infection from 1981 to 1984, including episodes arising in a logistics unit and at naval establishments, supports a significant contribution from the communal living, catering and tropical conditions of his naval service.
Each episode was acute and resolved with treatment, and there is no record that his duties prolonged or aggravated any of them.
Conclusion the veteran's acute enteritis was an acute infective illness of the bowel, the most prolonged of repeated episodes of gastroenteritis recorded between January 1981 and July 1984, for which no specific organism was identified.
The infections arose during his naval service, in the communal catering, water and living conditions of ships and naval establishments, including tropical service in a logistics unit and a logistics unit's deployment of early 1983, which are recognised settings for the spread of enteric infection.
A dietary or household source is possible for some episodes, but on the evidence his service contributed to the enteritis to a significant degree.
The % contribution of the causes is 100% and significant
Sequelae
No specific sequelae documented
Unintended Consequence
Not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
Each episode was assessed promptly during service, with hospital admission, stool cultures and empirical treatment for the July 1984 illness, and each resolved, so there is no evidence of inability to obtain appropriate clinical management — NOT MET
Date of Clinical Onset
Acute enteritis is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: 29 January 1981 — first documented episode of gastroenteritis [CHART REVIEW document].
The later records, including the further episodes in 1982 1984, including acute viral gastroenteritis at a logistics unit on 5 October 1982, including admission to RANH a logistics unit with acute enteritis on 16 2 August 1984, concern investigation or follow-up and do not alter the date of clinical onset.
Date of clinical onset: 29 January 1981.
This date falls within the veteran's ADF service (16 January 1979 1 November 1985).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
