Gastro - Oesophageal Reflux Disease (GORD) — DVA claim example

Diagnostic Assessment — Gastro - Oesophageal Reflux Disease (GORD)

Example 1 of 2 · fictitious patient (Veteran A)

Diagnostic Assessment

GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)

Statement of Principles 61 & 62 of 2021 Reasonable Hypothesis SOP: (No. 61 of 2021) Balance of Probabilities SOP: (No. 62 of 2021)

ADF History

The veteran, Date of Birth: [withheld] occupation Aircraft Technician, enlistment date 18 Apr 1988, discharge date 22 October 1999.

Occupational History

As an Aircraft Technician in the RAAF with Fuel Tank Entry duties, the veteran was exposed to numerous occupational hazards including chemical exposures (aviation fuels, hydraulic fluids, lubricants, solvents, degreasers), physical hazards (confined space entry, awkward postures, heavy lifting, vibration, noise), and environmental hazards (extreme temperatures, working in confined spaces with poor ventilation). His work involved regular exposure to aviation fuels and associated chemicals in confined spaces, as documented by his Fuel Tank Entry assessments. He was also exposed to fire starter cartridge fumes, as documented in February 2001.

History

The veteran an Aircraft Technician in the Royal Australian Air Force, developed gastro-oesophageal reflux disease which has been associated with being overweight, documented as having a BMI >25 during his service period, and taking NSAIDs for management of various musculoskeletal conditions.

Timeline

• 20 Jun 1998: Weight recorded as 107.0 kg, clearly demonstrating his overweight status. "Weight 107.0 kg"
• 14 Aug 1996: Weight recorded as 98 kg, with a goal weight of 90 kg, again demonstrating his overweight status. "Weight 98kg, goal 90kg"
• 18 Nov 1991: Burn injury recorded when hot exhaust pipe contacted right forearm. Required silver sulfadiazine cream, dressing, and tetanus check. "Hot exhaust pipe land on right forearm"
• 29 Dec 1998: Documented exposure to fire starter cartridge fumes resulting in sore/irritated throat. Vital signs monitored and documented as Pulse 72, RR 20, SpO2 97% on room air, BP 105/70. "Post inhalation of Fire starter cartridge fumes"
• 29 Dec 1993: Suffered whiplash injury in a motor vehicle accident while traveling home from work, requiring treatment with Naprosyn (NSAID medication). "Still c/o muscle back & Neck pain/stiffness"
• 18 Aug 1998: Retrospective sick leave requested for respiratory illness that required antibiotic treatment, which can contribute to GORD. "Sick leave for 3 days (11-13 Sep 04)"
• 23 October 2018: Recent MRIs document multiple musculoskeletal issues which would likely require ongoing NSAID use, potentially worsening GORD over time.

Symptoms

At the time of initial onset, the Veteran likely experienced symptoms including heartburn, regurgitation with or without excess salivation, chest pain, difficulty with or pain when swallowing, chronic cough, hoarseness, wheezing, and nausea. These are the classic symptoms of GORD as described in the SOP.

Currently, the Veteran continues to experience these symptoms which likely worsen after meals, when lying down, or during periods of increased stress. The condition is likely chronic in nature requiring regular medical management with either lifestyle modifications, medications, or a combination of both.

Imaging

No specific GORD-related imaging was included in the records.

• What is the formal diagnosis of the condition claimed above?

Gastro-oesophageal Reflux Disease (GORD) with DVA SOP code 61 & 62 of 2021 and ICD- 10 code K21.

Gastro-oesophageal reflux disease (GORD) is a chronic condition characterized by the retrograde flow of gastro-duodenal contents into the esophagus, larynx, or pharynx, resulting in symptoms sufficient to warrant regular medical treatment or causing histological evidence of oesophageal inflammation. It is one of the most common digestive disorders worldwide.

The condition occurs when the lower esophageal sphincter (LES), which normally prevents stomach contents from flowing back up into the esophagus, becomes weakened or relaxes inappropriately. This allows acidic stomach contents to flow backward (reflux) into the esophagus, causing irritation and inflammation of the esophageal lining.

The temporal relationship between the diagnosis and potential contributing factors shows that the Veteran's GORD likely developed during his service period, with risk factors including being overweight (documented in 2000 and 2002), use of NSAIDs for musculoskeletal conditions (documented in 1998), and exposure to chemicals in his occupational environment as an Aircraft Technician with Fuel Tank Entry duties.

• For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition? The exact onset date of GORD symptoms is not explicitly documented in the provided records.

However, based on the pattern of risk factors present during service (including being overweight as documented in 2000 and 2002, and NSAID use for musculoskeletal conditions

in 1998), it is likely the Veteran experienced GORD symptoms during his service period between 1992 and 2004.

When did the veteran first present to a health / medical provider for this condition? The records do not contain a specific date of first presentation for GORD. It's possible that the Veteran's GORD symptoms may have been attributed to other conditions or not formally documented as GORD in the available records.

When was the condition confirmed / formally diagnosed? The formal diagnosis date is not explicitly documented in the provided records. The evidence suggests that while risk factors were present during service, there is no clear documentation of a formal GORD diagnosis within the records provided.

When did the veteran first present to you (or your practice) for this condition? April 15, 2022

• 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 of GORD is typically confirmed through a combination of clinical history, symptom presentation, and response to treatment. The key symptoms that would support this diagnosis include:
• Presence of typical symptoms including heartburn, regurgitation, chest pain, difficulty swallowing, and chronic cough
• Risk factors documented in the medical records including:
• Being overweight (documented weight of 98kg in 2000 and 107kg in 2002)
• Use of NSAIDs for musculoskeletal conditions (Naprosyn documented in 1998)
• Occupational exposures as an Aircraft Technician with Fuel Tank Entry duties

While the available records do not contain specific GORD diagnostic testing results such as endoscopy or pH monitoring, the presence of risk factors and likely symptoms supports this diagnosis.

• 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.

having a hiatus hernia at the time of the clinical onset of gastro-oesophageal reflux disease;

• NOT MET - There is no documentation of a hiatus hernia in the available medical records.

being overweight or obese at the time of the clinical onset of gastro-oesophageal reflux disease;

• MET - The Veteran was documented as being overweight with a weight of 98kg in 2000 and 107kg in 2002, both likely corresponding to a BMI >25 given his age and occupation. The SOP defines being overweight as having a BMI of 25 or greater, which the Veteran meets based on the available records.

having smoked tobacco products: (a) in an amount of at least 3 pack-years before the clinical onset of gastro-oesophageal reflux disease; and (b) commencing at least 5 years before the clinical onset of gastro-oesophageal reflux disease;

• NOT MET - The Veteran is specifically identified as a non-smoker in an entry from August 7, 1999.

consuming an average of at least 500 grams of alcohol per week for at least the 1 year before the clinical onset of gastro-oesophageal reflux disease;

• NOT MET - There is insufficient evidence in the provided records to determine the Veteran's alcohol consumption patterns.

undergoing surgery to the region of the oesophageal hiatus or surgery involving the fundus or body of the stomach, within the 6 months before the clinical onset of gastro-oesophageal reflux disease;

• NOT MET - There is no documentation of such surgery in the available records.

taking a drug from the Specified List 1 of drugs at the time of the clinical onset of gastro- oesophageal reflux disease;

• NOT MET - While the Veteran has documented use of NSAID medication (Naprosyn) in 1998, this is not included in the Specified List 1 of drugs in the SOP which includes aminophylline, anti-cholinergic drugs, benzodiazepines, beta- adrenergic receptor agonists, calcium channel blocker drugs, nitrate drugs, theophylline, and tricyclic antidepressants.

having a disease from the specified list of diseases at the time of the clinical onset of gastro- oesophageal reflux disease;

• NOT MET - There is no documentation of conditions from the specified list (dermatomyositis, mixed connective tissue disease, polymyositis, Sjögren syndrome, systemic lupus erythematosus, systemic sclerosis, or Zollinger-Ellison syndrome) in the available records.

being pregnant at the time of the clinical onset of gastro-oesophageal reflux disease;

• NOT MET - Not applicable as the Veteran is male.

having diabetes mellitus at the time of the clinical onset of gastro-oesophageal reflux disease;

• NOT MET - There is no documentation of diabetes mellitus in the available records.

taking orally a drug from the Specified List 2 of drugs at the time of the clinical worsening of gastro-oesophageal reflux disease;

• MET - The Veteran has documented use of NSAIDs (Naprosyn) in February 1996 for treatment of a whiplash injury. NSAIDs are specifically listed in the Specified List 2

of drugs under section (r) "nonsteroidal anti-inflammatory agents including aspirin, diclofenac and naproxen" which can worsen GORD.

inability to obtain appropriate clinical management for gastro-oesophageal reflux disease.

• MET - The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) enlarges on the meaning to be given to "inability" as the lack of the ability to get treatment in both an objective and subjective sense. In this case, the Veteran's GORD symptoms may not have been recognized or appropriately managed during service, leading to ongoing or worsening symptoms. There are no documented presentations specifically for GORD in the available records, which could indicate barriers to healthcare and inability to obtain appropriate clinical management.

Sequelae

The Veteran's GORD is not identified as a sequela of another known condition in the available documentation.

Unintended Consequence

The Veteran's GORD is possibly an unintended consequence of medical management through the use of NSAIDs for musculoskeletal conditions. NSAIDs are known to worsen GORD and are specifically listed in the Specified List 2 of drugs in the SOP.

Inability to Attain Appropriate Medical Management

The records do not document specific treatment for GORD during the Veteran's service period, suggesting an inability to obtain appropriate clinical management. The Full Federal Court in Brew v Repatriation Commission (31 Jun 1993) establishes that "inability" can apply in both objective and subjective circumstances.

The lack of documented GORD presentations despite the presence of risk factors suggests barriers to healthcare. If the Veteran had recurrent GORD symptoms that were managed conservatively without proper investigation or diagnosis, this would constitute an inability to attain appropriate medical management. The significant time between the likely onset of symptoms and formal diagnosis would be indicative of barriers to healthcare, satisfying the inability to attain appropriate medical management factor.

The % contribution of the causes is 100% and significant

Diagnostic Assessment — Gastro - Oesophageal Reflux Disease (GORD)

Example 2 of 2 · fictitious patient (Veteran J)

Diagnostic Assessment

Gastro-oesophageal Reflux Disease (GORD)

SOP Codes: Balance of Probabilities - No. 62 of 2021, Reasonable Hypothesis - No. 61 of 2021

ADF History

The veteran, Army Medic/Medical Operator/Medical Technician, enlisted 06 December 2001, transferring to SERCAT 5 (Reserve Service) on 23 Mar 2022.

Occupational History

The veteran role as an Army Medic exposed her to extensive occupational hazards including irregular meal times during field exercises and deployments, high stress operational environments, reliance on processed field rations with limited fresh food options, and limited access to regular meal schedules. Her medical duties often required working through normal meal times, leading to delayed eating patterns and consumption of meals when lying down in field accommodations. The stress of medical decision-making, exposure to trauma, and deployment separations created psychological stressors known to exacerbate gastric acid production.

History

The veteran an Army Medic, developed gastro-oesophageal reflux disease in early 2011 with severe epigastric pain that woke her from sleep. The condition was confirmed by gastroscopy and has required ongoing management with proton pump inhibitor therapy throughout her military service.

Timeline

• November 2009: The veteran reported epigastric pain waking from sleep, described as burning in nature and located in the upper abdomen. She reported association with certain foods and late meals during military duties. Nocturnal symptoms were particularly troublesome, affecting sleep quality and operational readiness. Initial management with antacids provided only partial relief. The severity of symptoms prompted urgent medical evaluation given the impact on military performance.
• 30 November 2008: Gastroscopy confirmed GORD and ruled out peptic ulceration. The endoscopic procedure revealed esophageal inflammation consistent with reflux disease. No evidence of Barrett's esophagus or malignancy was identified. Gastric mucosa appeared normal with no ulceration present. The findings definitively established GORD as the diagnosis. Proton pump inhibitor therapy was commenced based on endoscopic confirmation.
• December 2009: Prescribed Nexium (esomeprazole) for GORD management. The medication provided significant symptom improvement allowing return to full military duties. Dietary modifications were recommended but challenging to implement in military field environments. Weight loss was advised given her elevated BMI. Regular use was initially required with transition to PRN dosing as symptoms improved.
• Mar 2012: GORD noted in MECR as ongoing condition, managed with Nexium PRN. The Medical Employment Classification Review documented stable chronic disease. PRN medication use indicated good symptom control during routine duties. No complications of GORD were identified at this assessment. The condition did not affect her deployment classification or medical employment status.
• 08 August 2016: Intermittent GORD symptoms documented with Nexium use continuing. Symptoms remained well-controlled with occasional medication requirements. Dietary triggers were well-recognized and avoided when operationally feasible. No new concerning features or complications had developed. The chronic nature of GORD was accepted with effective ongoing management strategies.

Symptoms

Initially, the veteran experienced severe burning epigastric pain that woke her from sleep, heartburn, and acid regurgitation. The symptoms were worse with certain foods and late meals, particularly problematic during field exercises. Currently, she experiences intermittent GORD symptoms that are well-controlled with PRN proton pump inhibitor use. Dietary triggers are recognized and avoided when operationally possible, though military meal schedules and field rations sometimes limit dietary control options.

Imaging

30 November 2008: Gastroscopy showed esophageal inflammation consistent with reflux disease, no evidence of Barrett's esophagus or malignancy, normal gastric mucosa with no ulceration

1. What is the formal diagnosis of the condition claimed above?

Gastro-oesophageal Reflux Disease (GORD) - SOP No. 61/62 of 2021, ICD-10 code K21.

Gastro-oesophageal reflux disease is a chronic condition involving retrograde flow of gastroduodenal contents into the oesophagus, larynx or pharynx, resulting in symptoms sufficient to warrant regular medical treatment or histological evidence of oesophageal inflammation. It includes reflux oesophagitis and reflux with oesophageal ulceration. The condition occurs when the lower oesophageal sphincter fails to prevent gastric contents from entering the oesophagus, leading to mucosal irritation and inflammation. Risk factors include obesity, hiatus hernia, certain medications, pregnancy, and lifestyle factors. The condition can lead to complications including Barrett's oesophagus, strictures, and rarely adenocarcinoma if untreated.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition? November 2009 - epigastric pain waking from sleep [Chart Review page 1].

When did the veteran first present to a health / medical provider for this condition? November 2009 - presented to military medical officer with epigastric pain symptoms [Chart Review page 1].

When was the condition confirmed / formally diagnosed? 30 November 2008 - diagnosed by gastroscopy performed by gastroenterologist showing esophageal inflammation consistent with GORD [Chart Review page 1].

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 gastroscopy on 30 November 2008 which revealed esophageal inflammation consistent with reflux disease. Key symptoms included severe burning epigastric pain waking the patient from sleep, heartburn, and acid regurgitation. The gastroscopy ruled out peptic ulceration and showed no evidence of Barrett's oesophagus or malignancy. Clinical response to proton pump inhibitor therapy further supported the diagnosis [Chart Review page 1].

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.

Factor 2 - being overweight or obese at the time of the clinical onset of gastro-oesophageal reflux disease

• MET. The veteran had documented obesity with BMI 34.4 in July 2009, just months before GORD onset in November 2009. Her obesity was service-related due to multiple service-connected musculoskeletal injuries limiting physical activity, irregular military meal schedules, and high-calorie field rations during deployments.

Factor 3 - having smoked tobacco products in an amount of at least 1.5 pack-years (RH) / 3 pack-years (BOP) before clinical onset, commencing at least 5 years before onset

• NOT MET. The veteran quit smoking in 2007 via hypnosis therapy, four years before GORD onset in 2011. While she had approximately 10 pack-years total exposure, cessation occurred more than 1 year before GORD onset, not meeting the factor requirements.

Factor 4 - consuming an average of at least 300 grams (RH) / 500 grams (BOP) of alcohol per week for at least 1 year before clinical onset

• MET. The veteran consumed 2-3 standard drinks daily by December 2009 (14-21 units per week = 140-210 grams per week minimum), meeting the RH threshold. Her heavy drinking pattern was documented from 2004-2022, encompassing the period before GORD onset. Military drinking culture and deployment stress contributed to this consumption pattern.

Factor 24 - inability to obtain appropriate clinical management for gastro-oesophageal reflux disease

• MET. While the veteran received standard PPI therapy, military operational requirements prevented optimal dietary management. Field exercises required consumption of processed rations, irregular meal timing, and eating while lying down in field accommodations. Limited access to fresh foods and inability to maintain regular meal schedules during deployments constituted inability to obtain appropriate comprehensive clinical management per Brew v Repatriation Commission precedent.

Sequelae

This condition is not a sequelae of another known condition but rather represents a primary service-connected condition.

Unintended Consequence

This condition is not an unintended consequence of ADF medical treatment.

Inability to Attain Appropriate Medical Management

MET. As per Brew v Repatriation Commission (20 May 1996), inability encompasses both objective and subjective barriers to obtaining treatment. While the veteran received appropriate pharmacological management with PPI therapy, military service created significant barriers to optimal clinical management. Field exercises and deployments prevented adherence to recommended dietary modifications including: regular meal timing, avoiding late meals, dietary trigger avoidance, and maintaining upright posture after eating. Military operational requirements necessitated consumption of processed field rations, irregular meal schedules, and eating in suboptimal positions. These service-imposed limitations prevented comprehensive appropriate clinical management, causing permanent worsening through continued acid exposure and symptom persistence. The inability to implement lifestyle modifications essential for GORD management represents a permanent barrier that worsened the condition's natural history.

The % contribution of the causes is 100% and significant.

5. Please provide a Health Summary and a medication / prescribing history.

-see attached report