Diagnostic Assessment — Haemorrhoids
Example 1 of 1 · fictitious patient
Diagnostic Assessment Haemorrhoids BOP Code: 20 of 2026 (Haemorrhoids) RH Code: 19 of 2026 (Haemorrhoids)
ADF History
The veteran, date of birth [withheld], Australian Army, Rifleman, 19 June 1980 to 5 April 1987
Occupational History
Australian Army service involves prolonged sitting, standing, heavy lifting, and dietary factors that are recognised risk factors for the development of haemorrhoids.
The veteran also had documented obesity during service (BMI 32.3 from May 1984), which is a significant risk factor for haemorrhoids due to increased intra-abdominal pressure
History
The veteran presented with per rectal bleeding during ADF service on 2 August 1985 at an infantry battalion.
He had fresh blood on toilet paper and in the toilet bowl.
Proctoscopy was performed and found no haemorrhoids, fissures, or other visible lesions, and no source of bleeding was identified.
He was referred to a surgeon for further assessment.
Whilst the proctoscopy on that occasion did not identify haemorrhoids, the presentation with rectal bleeding during service is documented.
Under DVA legislation, the absence of a positive finding on a single examination does not exclude the condition from having been present on other occasions.
Internal haemorrhoids were subsequently diagnosed by the Medical Officer on 25 September 1986 at an infantry battalion, when he again noticed blood on the toilet paper after passing a motion following heavy lifting.
The record notes that he had previously been investigated for rectal blood loss with no abnormality detected, and that no examination was performed on that occasion.
He was reassured and returned to duty
Timeline
2 August 1985 — ABSR the veteran presented with recent per rectal bleeding at an infantry battalion.
Fresh blood was noted around the anus and in the anal canal.
Proctoscopy was performed and showed no haemorrhoids, fissures, or other lesions.
No source of bleeding was identified.
He was referred to a surgeon for further assessment. "Per rectal bleeding" 25 Sep 1986 — ABSR the veteran presented at an infantry battalion having noticed blood on the toilet paper after passing a motion following heavy lifting; he was unsure whether there was blood on the stool as the toilet had just been cleaned.
He had previously been investigated for PR blood loss (NAD).
No examination was done.
Diagnosed with internal haemorrhoids (ICD 455), reassured and returned to duty. "Internal haemorrhoids"
Symptoms
Per rectal bleeding with fresh blood on toilet paper and in the toilet bowl.
No haemorrhoids identified on proctoscopy at that presentation, however the symptom of per rectal bleeding is consistent with haemorrhoids as the most common cause.
Further bleeding, with blood on the toilet paper after passing a motion following heavy lifting, was recorded on 25 September 1986, when internal haemorrhoids were diagnosed
Imaging
No imaging related to this condition
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Haemorrhoids (ICD-10: K64.9).
The relevant Statements of Principles are those concerning Haemorrhoids (Balance of Probabilities No.
20 of 2026; Reasonable Hypothesis No.
19 of 2026), applied by analogy as this is a DRCA claim.
Haemorrhoids are swollen vascular cushions in the anal canal that can cause bleeding, pain, and prolapse
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? Prior to 2 August 1985 (per rectal bleeding) [CHART REVIEW document] When did the veteran first present to a health / medical provider for this condition? 2 August 1985 When was the condition confirmed / formally diagnosed? 25 September 1986 (internal haemorrhoids, ICD 455, diagnosed by the Medical Officer at an infantry battalion) [CHART REVIEW document].
Haemorrhoids were not identified on proctoscopy on 2 August 1985.
The claim has been accepted for assessment by DVA.
When did the veteran first present to you (or your practice) for this condition? 30 October 2021
3. How was this diagnosis confirmed?
Per rectal bleeding was clinically documented on 2 August 1985.
Proctoscopy performed on that date did not identify haemorrhoids, however the symptom of per rectal bleeding during service is documented [CHART REVIEW document].
Internal haemorrhoids (ICD 455) were clinically diagnosed by the Medical Officer at an infantry battalion on 25 September 1986, on a history of blood on the toilet paper after passing a motion following heavy lifting; no examination was performed on that occasion [CHART REVIEW document]
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 16 September 2000 (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.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
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.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Haemorrhoids, No.
20 of 2026) Factor 9(1): being pregnant within the 6 weeks before clinical onset or clinical worsening — NOT MET - This factor cannot apply to the veteran, who is a man.
Factor 9(2): straining at stool due to constipation or diarrhoea, within the 2 weeks before clinical onset or clinical worsening — NOT MET - No constipation or diarrhoea is recorded in the 2 weeks before the estimated clinical onset of 3 June 1986.
His last diarrhoeal illness, the acute enteritis for which he was admitted to RANH an infantry battalion on 16 4 January 1986, had settled five months earlier, and a normal bowel habit was recorded on 10 January 1986.
Factor 9(3): having a spinal cord injury at the time of the clinical onset or clinical worsening — NOT MET - There is no record of a spinal cord injury at or before the estimated clinical onset of 3 June 1986; his in-service back injuries were soft-tissue strains without any deficit of spinal cord origin.
Factor 9(4): chewing khat at least weekly, for at least the 3 months before clinical onset or clinical worsening — NOT MET - There is no record of khat use, and nothing in his history suggests it.
Factor 9(5): an inability to consume an average daily intake of 20 grams of fibre in food for at least the 3 months before clinical onset — NOT MET - In the 3 months before the estimated clinical onset of 3 June 1986 the veteran was serving ashore at an infantry battalion in Sydney, where an ordinary diet was available; no dietary restriction is recorded, and his last sea posting, in an infantry battalion, had ended in mid-1984.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Haemorrhoids, No.
19 of 2026) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): being pregnant within the 6 weeks before clinical onset or clinical worsening — NOT MET - This factor cannot apply to the veteran, who is a man.
Factor 9(2): straining at stool due to constipation or diarrhoea, within the 2 weeks before clinical onset or clinical worsening — NOT MET - No constipation or diarrhoea is recorded in the 2 weeks before the estimated clinical onset of 3 June 1986; his last diarrhoeal illness, the acute enteritis of December 1985, had settled about five months earlier.
Factor 9(3): having a spinal cord injury at the time of the clinical onset or clinical worsening — NOT MET - No spinal cord injury is recorded at or before the estimated clinical onset of 3 June 1986; his in-service back injuries were soft-tissue strains without a cord deficit.
Factor 9(4): having a pelvic space occupying lesion of sufficient size to impinge on the rectal veins at clinical onset or clinical worsening — NOT MET - There is no record of a pelvic space-occupying lesion; proctoscopy on 2 August 1985 showed no lesion, and the pelvic viscera appeared normal on CT in December 2012.
Factor 9(5): chewing khat at least weekly, for at least the 3 months before clinical onset or clinical worsening — NOT MET - There is no record of khat use, and nothing in his history suggests it.
Factor 9(6): an inability to consume an average daily intake of 20 grams of fibre in food for at least the 3 months before clinical onset — NOT MET - In the 3 months before the estimated clinical onset of 3 June 1986 he was serving ashore at an infantry battalion in Sydney, and nothing suggests he was unable to obtain an ordinary diet providing 20 grams of fibre a day.
Factor 9(8): having irritable bowel syndrome for at least the 3 months before clinical onset — NOT MET - Irritable bowel syndrome has never been diagnosed; his episodes of diarrhoea in 1982 1985 were acute illnesses diagnosed as gastroenteritis, food poisoning or enteritis, and a normal bowel habit was recorded between them on 10 January 1986.
Factor 9(11): taking anticoagulants, antiplatelet agents, or nonsteroidal anti-inflammatory drugs within the 30 days before hemorrhoidal bleeding — NOT MET - No anticoagulant, antiplatelet agent or non-steroidal anti-inflammatory drug is recorded in the 30 days before any recorded rectal bleeding (2 August 1985, August 1985, 25 September 1986); the nearest were piroxicam (Feldene), continued by an orthopaedic surgeon on 25 May 1985, ten weeks before the July 1985 bleeding, and aspirin for tonsillitis on 19 June 1986, 14 weeks before the September 1986 bleeding.
Other Plausible Links to Service The bleeding that led to the diagnosis of internal haemorrhoids on 25 September 1986 came on when the veteran passed a motion after heavy lifting.
The record does not say where the lifting took place, but he was serving at an infantry battalion and presented to its sick bay on a working day, and heavy lifting was a routine part of his duties as a Rifleman and Rifleman (lifting steel cables and cable drums in September 1981, working ship's lines, and work with outboard motors in 1986).
Lifting against a closed glottis sharply raises intra-abdominal pressure and engorges the haemorrhoidal cushions, provoking bleeding and prolapse, so his duties contributed to the aggravation of his haemorrhoids.
The veteran was obese throughout the period in which his haemorrhoids developed (BMI 32.3 in 1984; 125 kg, BMI 35.7 and an abdominal girth of 115 cm at discharge).
Obesity is not a factor in the current Statements of Principles, but central obesity raises intra-abdominal pressure and impedes venous drainage from the haemorrhoidal plexus, and it is a plausible contributor; as his obesity itself arose during service and is separately claimed, any contribution it made would link his haemorrhoids to service as a sequela of that condition.
Conclusion the veteran's haemorrhoids developed during service, between his first presentation with rectal bleeding on 2 August 1985 and the diagnosis of internal haemorrhoids at an infantry battalion on 25 September 1986.
No onset factor of the current Statements of Principles is met on the records; the likely causes are raised intra-abdominal pressure from heavy lifting in the course of his duties, which immediately preceded the bleeding of 25 September 1986, and from the obesity that developed during his service, with the severe diarrhoeal illness of December 1985 a possible further contributor.
The incomplete investigation of his bleeding, the loss of his medical record and a diagnosis without examination or treatment meet the worsening factor for inability to obtain appropriate clinical management, so service also contributed to the persistence of the condition.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's haemorrhoids are found not to have arisen out of his service, the following factors address whether anything after their clinical onset (estimated 3 June 1986) aggravated them or contributed to them in a material degree.
The documented worsening is the recurrence of bleeding on 25 September 1986, when internal haemorrhoids were diagnosed at an infantry battalion; their course after his discharge on 5 April 1987 is not documented.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Haemorrhoids, No.
20 of 2026) Factor 9(1): being pregnant within the 6 weeks before clinical onset or clinical worsening — NOT MET - This factor cannot apply to the veteran, who is a man.
Factor 9(2): straining at stool due to constipation or diarrhoea, within the 2 weeks before clinical onset or clinical worsening — NOT MET - The only documented worsening after onset, the bleeding of 25 September 1986, followed heavy lifting, with no constipation or diarrhoea recorded in the 2 weeks before it.
Faecal loading on a x-ray in December 2012 and constipating medicines listed in 2020 (tapentadol, amitriptyline, quetiapine and olanzapine) suggest a later risk of straining, but no worsening of his haemorrhoids is documented after discharge.
Factor 9(3): having a spinal cord injury at the time of the clinical onset or clinical worsening — NOT MET - No spinal cord injury has been recorded at any time.
He reported a 'spinal stroke' in 2005 with complete recovery; the only recorded spinal imaging that year was a CT in July 2005 for acute right L5/S1 nerve-root pain, and no cord deficit has been recorded since.
Factor 9(4): chewing khat at least weekly, for at least the 3 months before clinical onset or clinical worsening — NOT MET - There is no record of khat use, and nothing in his history suggests it.
Factor 9(6): an inability to consume an average daily intake of 20 grams of fibre in food for at least the 4 weeks before clinical worsening — NOT MET - In the 4 weeks before the bleeding of 25 September 1986 the veteran was serving ashore at an infantry battalion in Sydney, and nothing suggests he was unable to obtain 20 grams of fibre a day; no dietary restriction is recorded after discharge.
Factor 9(7): taking anticoagulants, antiplatelet agents, or nonsteroidal anti-inflammatory drugs within the 30 days before hemorrhoidal bleeding for clinical worsening — NOT MET - No anticoagulant, antiplatelet agent or non-steroidal anti-inflammatory drug is recorded in the 30 days before the bleeding of 25 September 1986; the nearest was aspirin for tonsillitis on 19 June 1986, 14 weeks earlier.
No haemorrhoidal bleeding is recorded after discharge, and no anticoagulant or antiplatelet agent has been recorded at any time.
Factor 9(8): inability to obtain appropriate clinical management for haemorrhoids before clinical worsening — MET - the veteran's rectal bleeding was never fully investigated or treated in service.
After fresh bleeding with a normal proctoscopy on 2 August 1985 he was referred to a surgeon, and after a further episode in August 1985 a barium enema was ordered on 10 January 1986, but no result of either is recorded, and in May 1986 his medical record could not be located.
When the bleeding recurred on 25 September 1986, internal haemorrhoids were diagnosed without examination and he was only reassured, with no treatment or follow-up before discharge.
Assessed objectively and subjectively, as Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J) requires, this was an inability to obtain appropriate clinical management before the recurrence and persistence of his haemorrhoids.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Haemorrhoids, No.
19 of 2026) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): being pregnant within the 6 weeks before clinical onset or clinical worsening — NOT MET - This factor cannot apply to the veteran, who is a man.
Factor 9(2): straining at stool due to constipation or diarrhoea, within the 2 weeks before clinical onset or clinical worsening — NOT MET - No constipation or diarrhoea is recorded in the 2 weeks before the bleeding of 25 September 1986, which followed heavy lifting, and no worsening of his haemorrhoids is documented after discharge, despite faecal loading on a x-ray in December 2012 and constipating medicines listed in 2020.
Factor 9(3): having a spinal cord injury at the time of the clinical onset or clinical worsening — NOT MET - No spinal cord injury has been recorded at any time; the only recorded spinal imaging in 2005, the year of the 'spinal stroke' he reported with complete recovery, was for right L5/S1 nerve-root pain.
Factor 9(4): having a pelvic space occupying lesion of sufficient size to impinge on the rectal veins at clinical onset or clinical worsening — NOT MET - No pelvic space-occupying lesion has been recorded at any time; the abdominal and pelvic viscera appeared normal on CT in December 2012.
Factor 9(5): chewing khat at least weekly, for at least the 3 months before clinical onset or clinical worsening — NOT MET - There is no record of khat use, and nothing in his history suggests it.
Factor 9(7): an inability to consume an average daily intake of 20 grams of fibre in food for at least the 4 weeks before clinical worsening — NOT MET - In the 4 weeks before the bleeding of 25 September 1986 he was serving ashore at an infantry battalion in Sydney, and nothing suggests he was unable to obtain 20 grams of fibre a day, then or after discharge.
Factor 9(9): having irritable bowel syndrome for at least the 4 weeks before clinical worsening — NOT MET - Irritable bowel syndrome has not been diagnosed at any time, either before the bleeding of 25 September 1986 or after discharge.
Factor 9(10): having receptive anal intercourse within the 48 hours before clinical worsening — NOT MET - There is no record of receptive anal intercourse in the 48 hours before any documented worsening of his haemorrhoids.
Factor 9(12): inability to obtain appropriate clinical management for haemorrhoids before clinical worsening — MET - In service the veteran's rectal bleeding was never fully investigated or treated: the surgical referral of 2 August 1985 and the barium enema ordered on 10 January 1986 have no recorded result, his medical record could not be located in May 1986, and on 25 September 1986 internal haemorrhoids were diagnosed without examination and managed by reassurance alone, with no follow-up before discharge.
Assessed objectively and subjectively under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), this was an inability to obtain appropriate clinical management before the recurrence and persistence of his haemorrhoids
Sequelae
No specific sequelae documented
Unintended Consequence
Not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
This applies only to worsening.
MET — The veteran's rectal bleeding was never fully investigated or treated in service.
After fresh bleeding with a normal proctoscopy on 2 August 1985 he was referred to a surgeon, and after a further episode in August 1985 a barium enema was ordered on 10 January 1986, but no result of either is recorded, and in May 1986 his medical record could not be located.
When the bleeding recurred on 25 September 1986, internal haemorrhoids were diagnosed without examination and he was only reassured, with no treatment or follow-up before discharge.
Assessed objectively and subjectively, as Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J) requires, this was an inability to obtain appropriate clinical management before the recurrence and persistence of his haemorrhoids
Date of Clinical Onset
Haemorrhoids are a chronic condition.
Their date of clinical onset is the date on which the condition first manifested clinically.
It is not the date on which the condition was first imaged or formally diagnosed
Imaging
And specialist diagnosis record when an established condition was confirmed; a chronic condition is present, and usually symptomatic, for a considerable period before it is investigated, so the date of imaging must not be taken as the date of clinical onset.
First documented presentation with rectal bleeding: 2 August 1985 — fresh rectal bleeding, referred to a surgeon (an infantry battalion) [CHART REVIEW document].
End of ADF service: 5 April 1987.
First imaging / formal diagnosis (confirmation, not onset): 25 September 1986 (internal haemorrhoids diagnosed by the Medical Officer at an infantry battalion [CHART REVIEW document]).
The precise date of clinical onset cannot be determined from the records.
It is therefore estimated as the midpoint between the first documented presentation with rectal bleeding (2 August 1985) and the end of the veteran's ADF service (5 April 1987).
Estimated date of clinical onset: 3 June 1986.
This date falls within the veteran's ADF service (19 June 1980 5 April 1987).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
