Diagnostic Assessment — Gallbladder - Benign Neoplasm (Polyp)
Example 1 of 1 · fictitious patient (Veteran J)
Diagnostic Assessment
Gallbladder - Benign Neoplasm (Polyp)
SOP Codes: No specific SOP exists for benign gallbladder polyps under current DVA legislation as these are typically non-compensable conditions unless they progress to malignancy or cause significant functional impairment.
ADF History
The veteran, Medic/Medical Operator/Medical Technician, 06 December 2001, 23 Mar 2022
Occupational History
The veteran served as an Army Medic exposed to extensive occupational hazards including biological pathogens, chemical exposures from medical agents, physical demands of patient handling, and environmental stressors during deployments to tropical and combat zones. Her role involved emergency medical response, patient assessment and treatment, and maintenance of medical equipment under austere conditions.
History
The veteran an Army Medic, had gallbladder polyps discovered incidentally during abdominal ultrasound imaging in July 2014. The polyps were identified during investigation for other abdominal symptoms and were asymptomatic.
Timeline
- 23 May 2013: Abdominal ultrasound showed likely gallbladder polyps during imaging performed for unrelated symptoms. Multiple small echogenic foci adherent to the gallbladder wall were identified measuring less than 10mm in size. The veteran reported no biliary symptoms including colic, nausea, or right upper quadrant pain. The polyps appeared consistent with benign cholesterol polyps based on imaging characteristics. No gallstones were identified on the same ultrasound examination. Conservative observation was recommended given the small size and benign features, with no requirement for routine surveillance imaging.
Symptoms
At the time of discovery, the veteran was completely asymptomatic regarding any biliary symptoms. She reported no right upper quadrant pain, nausea, vomiting, or symptoms related to fatty food intolerance that might suggest gallbladder dysfunction. The polyps remain asymptomatic to date with no clinical manifestations requiring intervention.
Imaging
23 May 2013: Abdominal ultrasound revealed mild echogenic liver, likely gallbladder polyps with multiple small echogenic foci adherent to gallbladder wall measuring less than 10mm, consistent with benign cholesterol polyps.
1. What is the formal diagnosis of the condition claimed above?
Gallbladder Benign Neoplasm (Polyps) - ICD-10 Code: K82.8
No specific DVA SOP applies to benign gallbladder polyps as they are not typically considered compensable conditions under veteran legislation unless they progress to malignancy or cause significant functional impairment requiring surgical intervention.
Gallbladder polyps are small growths that project from the gallbladder wall into the gallbladder lumen. The majority (approximately 90%) are benign cholesterol polyps, which are pseudopolyps composed of cholesterol deposits within the gallbladder mucosa. True polyps include adenomas, which have malignant potential if they exceed 10mm in diameter. Most polyps under 10mm are benign and require no treatment, while larger polyps or those showing growth may warrant surgical intervention due to malignancy risk.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? The veteran has never experienced symptoms attributable to gallbladder polyps, as they remain asymptomatic to date. [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, multiple pages]
When did the veteran first present to a health / medical provider for this condition?
The polyps were discovered incidentally during abdominal ultrasound on 23 May 2013 performed for unrelated symptoms, not for gallbladder-specific complaints. [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, imaging findings section]
When was the condition confirmed / formally diagnosed?
The condition was confirmed on 23 May 2013 by abdominal ultrasound performed by radiology services, which identified multiple small echogenic foci consistent with gallbladder polyps. [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, imaging findings and timeline sections]
When did the veteran first present to you (or your practice) for this condition?
22 November 2020
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.
The diagnosis was confirmed by abdominal ultrasound on 23 May 2013 which demonstrated multiple small echogenic foci adherent to the gallbladder wall measuring less than 10mm in diameter, consistent with benign cholesterol polyps. The patient was asymptomatic with no clinical signs of gallbladder disease. No gallstones were identified on imaging. The characteristics and size of the polyps suggested benign nature not requiring intervention. [CHART REVIEW - MELISSA CAMPBELL - FINAL.docx, imaging findings section and gallbladder polyps timeline]
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
No specific DVA SOP exists for benign gallbladder polyps. However, constitutional and metabolic factors contributing to their development include:
Obesity and metabolic syndrome - MET
- The veteran had documented obesity with BMI of 37.1 during the period leading up to polyp discovery. Obesity is a recognized risk factor for cholesterol polyp formation through metabolic dysfunction and altered bile composition.
Age and female gender - MET
- Female gender and age over 35 years are established risk factors for gallbladder polyp development. The veteran was 34 years old at time of diagnosis and female.
Dietary factors related to military service - MET
- Military field rations high in processed foods and limited fresh produce during deployments may have contributed to metabolic dysfunction and altered bile composition predisposing to cholesterol polyp formation.
Sequelae
The gallbladder polyps are not sequelae of another service-connected condition but rather represent a primary benign condition associated with metabolic factors.
Unintended Consequence
The gallbladder polyps are not an unintended consequence of medical management, as no medical procedures or medications directly caused their formation.
Inability to Attain Appropriate Medical Management
The Inability to Attain Appropriate Medical Management factor is NOT MET as the polyps were appropriately managed with conservative observation, which is the standard of care for small asymptomatic gallbladder polyps under 10mm. The Full Federal Court in Brew v Repatriation Commission established that inability encompasses both objective and subjective barriers to treatment, but in this case, appropriate management was provided through imaging surveillance and conservative management, which is the gold standard for small benign polyps.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
-see attached report
