Inflammatory Bowel Disease — DVA claim example

Diagnostic Assessment — Inflammatory Bowel Disease

Example 1 of 1 · fictitious patient (Veteran CF)

Diagnostic Assessment

Inflammatory Bowel Disease

BOP Code: 91 of 2020 (Inflammatory Bowel Disease)
RH Code: 90 of 2020 (Inflammatory Bowel Disease)

ADF History

Veteran CF, date of birth 19 August 1982, Royal Australian Navy, Combat Systems Operator (Electronic Warfare), enlisted 08 February 2000, medically discharged 05 July 2021. Operational service: Middle East Area of Operations (North Arabian Gulf), aboard a frigate, 10 February 2007 to 20 August 2007 (warlike); Iraq, coalition headquarters, 10 November 2016 to 15 April 2017 (warlike); Middle East Area of Operations, deployed headquarters, 05 July 2018 to 16 November 2018 (warlike, ended by aeromedical evacuation).

Occupational History

As a combat systems operator the veteran worked long watches in ships' operations rooms and later in headquarters, in a sedentary role with shift work and disrupted sleep. Sea service on frigates and patrol boats meant weeks without fresh food, high exposure to ultraviolet light on upper decks, cramped messes and, in the period of her service, heavy exposure to tobacco smoke.

Deployed headquarters staff of the period were exposed to rocket and indirect fire, mass-casualty incidents at base gates, food-borne gastrointestinal infection and the strain of long separations from family. Menstrual suppression with the combined oral contraceptive pill was routinely prescribed to women at sea and on deployment.

History

Veteran CF, a Royal Australian Navy combat systems operator, developed inflammatory bowel disease on 20 March 2017 during warlike service at a coalition headquarters in Iraq, after a rocket attack and a mass-casualty bombing, while taking interferon for service-related melanoma, naproxen for a service injury and a combined oral contraceptive pill. It presented as ulcerative colitis, worsened severely on a second Middle East deployment in November 2018 and was reclassified as Crohn colitis in January 2019.

Timeline

• 14 Feb 2012 — While serving on a patrol boat the veteran fell down a steep ladder in heavy seas, sustaining a fracture-dislocation of the right hip and a crush injury of the right foot. On 03 April 2012 she underwent hip reconstruction with an osteochondral allograft and a tendon allograft to the foot. Naproxen 500 mg twice daily was started for post-traumatic pain and continued long term. An exercise physiologist later limited her to activity below 3 METs. BMI 35.8. "hip fracture-dislocation, allograft reconstruction"
• 10 Feb 2013 — A psychiatrist diagnosed major depressive disorder after the injury, with loss of career prospects and chronic pain. PHQ-9 19. Sertraline and psychology were commenced. She continued to smoke 15 cigarettes a day and was drinking about 1.5 litres of cola a day on night watches. "major depressive disorder, PHQ-9 19"
• 10 Jan 2016 — A dermatologist excised a melanoma from the veteran's upper back, and sentinel node biopsy and axillary dissection in February 2016 confirmed stage IIIB disease. Her oncologist attributed it to years of sun exposure on upper decks. Adjuvant pembrolizumab was given from 08 March 2016 to 13 September 2016, stopped for thyroiditis, and peginterferon alfa-2b was started on 10 October 2016. She had stopped smoking on 01 March 2015. "stage IIIB melanoma, pembrolizumab"
• 20 Oct 2016 — Pre-deployment health assessment before deployment to a coalition headquarters in Iraq. Normal bowel habit, no rectal bleeding or abdominal pain. Continuing peginterferon, naproxen and a combined oral contraceptive pill taken continuously since 2003. Approved to deploy in a desk-based role with medication storage arranged at the base medical facility. "normal bowel habit, approved deploy"
• 27 Mar 2017 — At the role 2 facility in Iraq the veteran reported bloody diarrhoea eight times a day with urgency, cramping and tenesmus since 20 March 2017. In the preceding two months a rocket had struck her accommodation block (22 January 2017), she had helped carry casualties and seen the dead after a gate bombing (03 February 2017), and her husband had ended their marriage (01 March 2017). Stool cultures were negative. No colonoscopy was available in theatre. "bloody diarrhoea, urgency, tenesmus"
• 05 May 2017 — Colonoscopy after her return to Australia showed continuous inflammation from the rectum to the splenic flexure with ulceration, and histology showed chronic active colitis with crypt distortion and crypt abscesses. A gastroenterologist diagnosed ulcerative colitis (Mayo endoscopic score 2) and started mesalazine. Interferon was stopped. Faecal calprotectin 1,450 micrograms per gram. "left-sided colitis, Mayo 2"
• 12 Nov 2018 — On warlike service in the Middle East the veteran developed severe bloody diarrhoea twelve times a day with fever, three weeks after Campylobacter enteritis, six weeks after a rocket strike on the next accommodation block and four weeks after witnessing a fatal vehicle rollover. She had restarted naproxen and had finished nivolumab for recurrent melanoma in May 2018. CRP 112 mg/L, haemoglobin 98 g/L. She waited four days for aeromedical evacuation. "severe flare, CRP 112"
• 20 Nov 2018 — Admitted under a gastroenterologist in Australia. CT showed pancolitis with thickening of the terminal ileum. Treated with intravenous hydrocortisone and then infliximab. Mayo score 11. "pancolitis, terminal ileitis, infliximab"
• 22 Jan 2019 — Ileocolonoscopy showed patchy colitis with rectal sparing in places, deep fissuring ulcers and terminal ileitis, and histology showed non-caseating granulomas. The gastroenterologist reclassified the disease as Crohn disease of the ileum and colon. She remained on infliximab with azathioprine. "granulomas, reclassified Crohn disease"

Symptoms

At onset the veteran had bloody diarrhoea up to eight times a day with urgency, cramping lower abdominal pain, tenesmus and fatigue. After onset she had partial control on mesalazine with intermittent bleeding and urgency. At the 2018 worsening she had severe bloody diarrhoea twelve times a day, fever, weight loss of 7 kg and anaemia.

She now reports three to five loose motions a day despite infliximab and azathioprine, urgency with occasional incontinence, crampy abdominal pain, fatigue and anxiety about leaving home without access to a toilet.

Imaging

• 20 Nov 2018 — CT abdomen and pelvis: "Pancolitis with diffuse mural thickening and pericolic fat stranding, and thickening of the terminal ileum over 12 cm. No perforation or abscess."
• 30 Jan 2019 — MR enterography: "Active inflammatory Crohn disease of the terminal ileum over 15 cm with mural hyperenhancement. Colonic wall thickening consistent with Crohn colitis. No fistula or stricture."

Onset Date

The most likely date of onset of this condition is 20 Mar 2017.

At that date the veteran was on warlike service at a coalition headquarters in Iraq, in a desk-based role. From that date she had persistent bloody diarrhoea with urgency and tenesmus, which she reported at the role 2 facility on 27 March 2017.

This date is appropriate because her pre-deployment assessment on 20 October 2016 recorded a normal bowel habit, and her first presentation on 27 March 2017 dated continuous symptoms to 20 March 2017. Colonoscopy on 05 May 2017 confirmed chronic active colitis. It falls within continuous full-time service.

For the stressor factors, the three months before onset run from 20 Dec 2016 to 20 Mar 2017 and contain the rocket strike of 22 Jan 2017 and the gate bombing of 03 Feb 2017; the 30 days before onset run from 18 Feb 2017 to 20 Mar 2017 and contain the marriage breakdown of 01 Mar 2017. For the drug factors, the seven days before onset run from 13 Mar 2017 to 20 Mar 2017 (peginterferon), the two months before onset from 20 Jan 2017 to 20 Mar 2017 (daily naproxen, last dose 19 Mar 2017), and the one year before onset from 20 Mar 2016 to 20 Mar 2017 (pembrolizumab, last dose 13 Sep 2016). The combined oral contraceptive pill was continuous from 12 Mar 2003. The depressive disorder was continuous through the year before onset. For the Crohn disease factors, the five years before onset run from 20 Mar 2012 to 20 Mar 2017 and contain three antibiotic courses (the last completed 01 Mar 2016), two years of high sucrose intake (Jul 2012 to Jun 2014) and continuous inability to exceed 3 METs from Feb 2012; the ten years before onset run from 20 Mar 2007 to 20 Mar 2017 and contain the low-fibre period of Apr 2007 to Apr 2012; the 20 years before onset contain 8 years of obesity from Jan 2009. She ceased smoking on 01 Mar 2015, 2 years before onset, and shipboard second-hand smoke exposure ceased on 30 Jun 2015.

For the worsening factors, the documented worsening was on 12 Nov 2018, with severe colitis, a CRP of 112 mg/L, pancolitis and new terminal ileitis on CT and escalation to infliximab. The three months before it run from 12 Aug 2018 to 12 Nov 2018 and contain the rocket strike of 30 Sep 2018 and the fatal rollover of 15 Oct 2018; the 30 days before it run from 13 Oct 2018 to 12 Nov 2018 and contain the divorce papers of 20 Oct 2018 and the Campylobacter infection of 25 Oct 2018; the seven days before it contain daily naproxen; and the one year before it contains nivolumab from Dec 2017 to May 2018. The worsening was 3 years and 8 months after she stopped smoking.

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

The formal diagnosis is Inflammatory Bowel Disease, presenting as ulcerative colitis and reclassified as Crohn disease of the ileum and colon (ICD-10-AM K50.8), under the Statements of Principles concerning inflammatory bowel disease, Balance of Probabilities No. 91 of 2020 and Reasonable Hypothesis No. 90 of 2020.

Inflammatory bowel disease is a chronic, relapsing and remitting inflammatory autoimmune disorder of the gastrointestinal tract, comprising Crohn disease, ulcerative colitis and inflammatory bowel disease of unspecified type. Ulcerative colitis causes continuous mucosal inflammation from the rectum upwards, while Crohn disease causes patchy, transmural inflammation that can affect any part of the gut, most often the terminal ileum and colon, with granulomas on histology. Both cause bloody diarrhoea, urgency, abdominal pain, weight loss and fatigue, and both carry risks of anaemia, strictures, fistulas, colorectal cancer and extra-intestinal disease. Early colitis often cannot be classified with certainty, and reclassification from ulcerative colitis to Crohn disease is well recognised.

The disease began on 20 March 2017 on warlike service in Iraq, was diagnosed on colonoscopy on 05 May 2017, worsened on 12 November 2018 on warlike service in the Middle East and was reclassified as Crohn disease on 22 January 2019.

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

When did the veteran first experience symptoms attributable to this condition?

20 March 2017.

When did the veteran first present to a health / medical provider for this condition?

27 March 2017.

When was the condition confirmed / formally diagnosed?

05 May 2017.

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

14 August 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed by colonoscopy and histology on 05 May 2017, which showed continuous colitis from the rectum to the splenic flexure with chronic active inflammation, crypt distortion and crypt abscesses, with negative stool cultures and a faecal calprotectin of 1,450 micrograms per gram. These findings met the criteria for ulcerative colitis at onset.

The ileocolonoscopy of 22 January 2019 showed patchy colitis, deep fissuring ulcers and terminal ileitis with non-caseating granulomas, confirmed on MR enterography, and the gastroenterologist reclassified the disease as Crohn disease. This is a chronic, relapsing and remitting inflammatory autoimmune disorder of the gastrointestinal tract within the Statement of Principles definition. Infective colitis was excluded by negative cultures at onset, and the inflammation persisted long after the 2018 Campylobacter infection had cleared.

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.

Legislation: the clinical onset of this condition was on 20 March 2017, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in the North Arabian Gulf in 2007, in Iraq in 2016-17, during which the onset occurred, and in the Middle East in 2018, during which the condition worsened. Because the disease met the criteria for ulcerative colitis at onset and was later reclassified as Crohn disease, both the ulcerative colitis and the Crohn disease factors have been analysed.

Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Balance of Probabilities — Statement of Principles concerning Inflammatory Bowel Disease, No. 91 of 2020

Causative factors

Factor 9(1): taking a nonsteroidal anti-inflammatory drug on at least ten days per month, for a continuous period of at least two months before the clinical onset of inflammatory bowel disease and the last dose of the drug was taken within the 14 days before the clinical onset of inflammatory bowel disease; — MET

- From 14 February 2012, after a fall down a ship's ladder fractured and dislocated her right hip and crushed her right foot, the veteran took naproxen 500 mg twice daily, prescribed by Defence medical officers for chronic post-traumatic pain. Pharmacy and medical records show daily use, well over ten days a month, continuously for five years, including the two months before onset from 20 January 2017 to 20 March 2017. Her last dose was taken on 19 March 2017, the day before the clinical onset.

Factor 9(2): taking an interferon or a tumour necrosis factor antagonist for at least the seven days before the clinical onset of inflammatory bowel disease; — MET

- The veteran took peginterferon alfa-2b by weekly subcutaneous injection from 10 October 2016 as adjuvant treatment for stage IIIB melanoma, a cancer her oncologist attributed to years of ultraviolet exposure on the upper decks of patrol boats and a frigate. She continued it throughout the seven days before onset, from 13 March 2017 to 20 March 2017. Interferons are recognised triggers of autoimmune colitis.

Factor 9(3): taking an immune checkpoint inhibitor within the one year before the clinical onset of inflammatory bowel disease; — MET

- The veteran received pembrolizumab, an immune checkpoint inhibitor, every three weeks from 08 March 2016 to 13 September 2016 as adjuvant treatment for melanoma, stopping because of immune-related thyroiditis. Her last dose was 6 months and 7 days before the clinical onset on 20 March 2017, within the one year before onset. Checkpoint inhibitors release immune tolerance and commonly cause immune-mediated colitis.

Factor 9(4): taking a combined oral contraceptive pill for a continuous period of at least one year before the clinical onset of inflammatory bowel disease and where taking the combined oral contraceptive pill has ceased, the clinical onset of inflammatory bowel disease has occurred within one year of cessation; — MET

- A naval medical officer prescribed a combined oral contraceptive pill (ethinylestradiol 30 micrograms with levonorgestrel) for continuous menstrual suppression during sea service from 12 March 2003. She took it without a break up to and beyond the onset on 20 March 2017, a continuous period of 14 years, well over the one year required, and it had not ceased at onset.

Factor 9(5): undergoing organ or tissue transplantation, excluding corneal transplant, before the clinical onset of inflammatory bowel disease; — MET

- On 03 April 2012 the veteran underwent reconstruction of her right hip with a fresh-frozen osteochondral allograft from a deceased donor, together with a tendon allograft to the right foot, for the injuries of 14 February 2012. This tissue transplantation, which is not a corneal transplant, took place before the clinical onset on 20 March 2017.

Factor 9(6): for Crohn disease only, having smoked at least two pack-years of tobacco products before the clinical onset of Crohn disease, and where smoking has permanently ceased, the clinical onset of Crohn disease has occurred within four years of cessation; — MET

- For Crohn disease: the veteran smoked 15 cigarettes a day from February 2000, beginning at recruit training, until she permanently stopped on 01 March 2015, a total of about 11 pack-years. The clinical onset on 20 March 2017 occurred 2 years after cessation, within four years. The colitis was reclassified as Crohn disease on ileocolonoscopy in January 2019.

Factor 9(7): for ulcerative colitis only, in a person with a prior history of a regular smoking habit as specified, permanently ceasing to smoke between one and 20 years before the clinical onset of ulcerative colitis; — MET

- For ulcerative colitis: the veteran had a regular smoking habit of 15 cigarettes a day for 15 years during service, which meets the specified habit, and permanently stopped on 01 March 2015. The clinical onset on 20 March 2017, when the colitis met the criteria for ulcerative colitis on colonoscopy of 05 May 2017, occurred 2 years after she stopped, between one and 20 years.

Worsening factors

Factor 9(8): taking a drug from the specified list of drugs for at least the seven days before the clinical worsening of inflammatory bowel disease; — MET

- From 15 October 2018 the veteran again took naproxen 500 mg twice daily, a drug from the specified list, for an exacerbation of post-traumatic right hip pain while deployed, continuing through the seven days before the worsening, from 05 November 2018 to 12 November 2018.

Factor 9(9): taking an immune checkpoint inhibitor within the one year before the clinical worsening of inflammatory bowel disease; — MET

- Melanoma recurred in a right axillary node in November 2017, and the veteran received nivolumab, an immune checkpoint inhibitor, every two weeks from 04 December 2017 to 28 May 2018. Her last dose was 5 months and 15 days before the worsening on 12 November 2018, within the one year before the worsening.

Factor 9(10): taking a combined oral contraceptive pill for a continuous period of at least one year before the clinical worsening of inflammatory bowel disease and where taking the combined oral contraceptive pill has ceased, the clinical worsening of inflammatory bowel disease has occurred within one year of cessation; — MET

- The combined oral contraceptive pill, taken continuously from 12 March 2003, was still being taken at the worsening on 12 November 2018, a continuous period of more than 15 years.

Factor 9(11): undergoing organ or tissue transplantation, excluding corneal transplant, before the clinical worsening of inflammatory bowel disease; — MET

- The osteochondral and tendon allograft transplantation of 03 April 2012 took place before the clinical worsening on 12 November 2018.

Factor 9(12): experiencing a category 1A stressor within the three months before the clinical worsening of inflammatory bowel disease; — MET

- On 30 September 2018 a rocket struck the accommodation block next to the veteran's at her deployed headquarters, killing two coalition personnel and blowing in her windows while she sheltered on the floor. This life-threatening event occurred 43 days before the worsening on 12 November 2018, within the three months before the worsening. It was recorded in the incident log and her mental health record.

Factor 9(13): experiencing a category 1B stressor within the three months before the clinical worsening of inflammatory bowel disease; — MET

- On 15 October 2018 the veteran was first on scene to help at a vehicle rollover near the headquarters and saw two critically injured soldiers, one of whom died in front of her. This eyewitness viewing of critically injured casualties occurred 28 days before the worsening, within the three months before it.

Factor 9(14): experiencing a category 2 stressor within the 30 days before the clinical worsening of inflammatory bowel disease; — MET

- On 20 October 2018, while deployed, the veteran was served with divorce papers and learned that her estranged husband was seeking sole custody of their child, and her mental health record documents marked, sustained distress. A serious problem with a long-term relationship is a category 2 stressor, and it occurred 23 days before the worsening on 12 November 2018, within the 30 days before it.

Factor 9(15): for Crohn disease only, having smoked at least two pack-years of tobacco products before the clinical worsening of Crohn disease, and where smoking has permanently ceased, the clinical worsening of Crohn disease has occurred within four years of cessation; — MET

- For Crohn disease: the veteran had smoked about 11 pack-years and permanently stopped on 01 March 2015. The worsening on 12 November 2018 occurred 3 years and 8 months after cessation, within four years, and ileocolonoscopy in January 2019 confirmed Crohn disease with terminal ileitis and granulomas.

Factor 9(16): inability to obtain appropriate clinical management for inflammatory bowel disease; — MET

- After onset the veteran waited six weeks on deployment for colonoscopy and had no gastroenterology care in theatre. In 2018 she was redeployed to the Middle East with a disease that had only partly responded to mesalazine, the azathioprine her gastroenterologist had recommended was deferred because blood monitoring was not available in theatre, and when she flared in November 2018 she waited four days for aeromedical evacuation. These failures of access arose from her service.

Reasonable Hypothesis — Statement of Principles concerning Inflammatory Bowel Disease, No. 90 of 2020

Causative factors

Factor 9(1): taking a drug from the Specified List 1 of drugs for at least the seven days before the clinical onset of inflammatory bowel disease; — MET

- The veteran took peginterferon alfa-2b weekly from 10 October 2016, including the seven days before onset from 13 March 2017 to 20 March 2017, while on warlike service at a coalition headquarters in Iraq, where it was stored in the medical facility's refrigerator. Interferon alfa is a drug on the Specified List 1. The melanoma it treated arose from ultraviolet exposure during her service, including her 2007 warlike deployment in the North Arabian Gulf.

Factor 9(2): taking a nonsteroidal anti-inflammatory drug on at least ten days per month, for a continuous period of at least two months before the clinical onset of inflammatory bowel disease and the last dose of the drug was taken within the 14 days before the clinical onset of inflammatory bowel disease; — MET

- The veteran took naproxen 500 mg twice daily every day from February 2012, including throughout the two months before onset from 20 January 2017 to 20 March 2017 while on warlike service in Iraq, and took her last dose on 19 March 2017, within 14 days of onset. It was prescribed for the post-traumatic hip and foot pain from her service injury.

Factor 9(3): taking an immune checkpoint inhibitor within the one year before the clinical onset of inflammatory bowel disease; — MET

- Pembrolizumab, an immune checkpoint inhibitor, was given from 08 March 2016 to 13 September 2016, within the one year before onset on 20 March 2017, for a melanoma linked to sun exposure during her service including her warlike deployment in 2007.

Factor 9(4): taking a combined oral contraceptive pill for a continuous period of at least six months before the clinical onset of inflammatory bowel disease and where taking the combined oral contraceptive pill has ceased, the clinical onset of inflammatory bowel disease has occurred within one year of cessation; — MET

- The veteran took a combined oral contraceptive pill continuously from 12 March 2003 for menstrual suppression during sea service and operational deployments, including her warlike service in Iraq from November 2016. It was ongoing at onset, a continuous period far longer than six months.

Factor 9(5): undergoing organ or tissue transplantation, excluding corneal transplant, before the clinical onset of inflammatory bowel disease; — MET

- The allograft tissue transplantation of 03 April 2012, for her service injury, took place before the clinical onset on 20 March 2017, which occurred on warlike service in Iraq.

Factor 9(6): experiencing a category 1A stressor within the three months before the clinical onset of inflammatory bowel disease; — MET

- On 22 January 2017, during warlike service at a coalition headquarters in Iraq, a rocket struck the veteran's accommodation block while she was in it, wounding two personnel and covering her in debris. This life-threatening event occurred 57 days before the clinical onset on 20 March 2017, within the three months before onset.

Factor 9(7): experiencing a category 1B stressor within the three months before the clinical onset of inflammatory bowel disease; — MET

- On 03 February 2017, during warlike service in Iraq, a vehicle-borne improvised explosive device detonated at the base gate. The veteran helped carry casualties to the aid post and saw the bodies of three people who had been killed. This occurred 45 days before onset, within the three months before it.

Factor 9(8): experiencing a category 2 stressor within the 30 days before the clinical onset of inflammatory bowel disease; — MET

- On 01 March 2017, while on warlike service in Iraq, the veteran learned by email that her husband had left the family home and was ending their marriage, and she was also being bullied by a senior officer in her section, both recorded by the deployed psychologist. These serious relationship and workplace problems are category 2 stressors and arose in the circumstances of her deployment. They occurred 19 days before onset, within the 30 days before it.

Factor 9(9): having a clinically significant depressive disorder or a clinically significant anxiety disorder for at least the one year before the clinical onset of inflammatory bowel disease; — MET

- A psychiatrist diagnosed major depressive disorder on 10 February 2013 after the 2012 service injury, with a PHQ-9 of 19, treated with sertraline and psychology. The depressive disorder was clinically significant and continuous for more than four years before onset, including the year before onset from 20 March 2016 to 20 March 2017, and it worsened on deployment in Iraq.

Factor 9(10)(a): for Crohn disease only: having smoked at least one pack-year of tobacco products before the clinical onset of Crohn disease, and where smoking has permanently ceased, the clinical onset of Crohn disease has occurred within four years of cessation; — MET

- The veteran smoked about 11 pack-years, starting at recruit training in 2000 and smoking more heavily at sea and on her 2007 warlike deployment, and permanently ceased on 01 March 2015. The onset of the disease, later classified as Crohn disease, on 20 March 2017 was within four years of cessation.

Factor 9(10)(b): for Crohn disease only: where exposure to second-hand smoke has not permanently ceased: (i) being exposed to second-hand smoke for at least 5,000 hours before the clinical onset of Crohn disease; and (ii) the first exposure to second-hand smoke commenced at least one year before the clinical onset of Crohn disease; — MET

- The veteran was exposed to second-hand smoke in the designated smoking area beside her office and in shared accommodation at the coalition headquarters in Iraq from November 2016, and this exposure had not permanently ceased at onset. Her total exposure to second-hand smoke in service, including ship's messes from 2000, exceeded 5,000 hours before the onset on 20 March 2017, and the first exposure began in February 2000, more than one year before onset.

Factor 9(10)(c): for Crohn disease only: where exposure to second-hand smoke has permanently ceased before the clinical onset of Crohn disease: (i) being exposed to second-hand smoke for at least 5,000 hours; and (ii) the first exposure to second-hand smoke commenced at least one year before the clinical onset of Crohn disease; and (iii) the clinical onset of Crohn disease has occurred within four years of the last exposure to second-hand smoke; — MET

- The veteran's shipboard second-hand smoke exposure in mess decks and enclosed smoking areas from February 2000 totalled about 5,400 hours, including her 2007 warlike deployment, and permanently ceased when she was posted ashore on 30 June 2015. That first exposure began more than one year before onset, and the onset on 20 March 2017 occurred 1 year and 9 months after the last shipboard exposure, within four years.

Factor 9(10)(d): for Crohn disease only: taking at least three courses of antibiotics within the five years before the clinical onset of Crohn disease, and the last course of antibiotics was completed at least six months before the clinical onset of Crohn disease; — MET

- In the five years before onset (20 March 2012 to 20 March 2017) the veteran took three courses of antibiotics: flucloxacillin for a hip wound infection in April 2012, cephalexin for cellulitis of the right foot under her orthosis in November 2014, and amoxicillin-clavulanate for an axillary wound infection after melanoma surgery, completed on 01 March 2016. The last course was completed 12 months before onset, at least six months before it.

Factor 9(10)(e): for Crohn disease only: inability to consume an average daily intake of at least ten grams of fibre in food for a period of at least five consecutive years within the ten years before the clinical onset of Crohn disease; — MET

- From 01 April 2007 to 30 April 2012 the veteran served on a frigate, including warlike service in the North Arabian Gulf in 2007, and then on patrol boats, where fresh food was unavailable for weeks at a time and meals were processed galley food. A dietitian's assessment on 18 June 2012 recorded an average fibre intake of about 7 grams a day over that period. This 5-year period lies within the ten years before onset (20 March 2007 to 20 March 2017).

Factor 9(10)(f): for Crohn disease only: consuming an average of at least 100 grams per day of sucrose, for at least two consecutive years within the five years before the clinical onset of Crohn disease; — MET

- From 01 July 2012 to 30 June 2014 the veteran worked night watches in a ship's operations room and drank about 1.5 litres of cola and energy drinks a day to stay alert, about 160 grams of sucrose daily, recorded at her 2013 and 2014 health assessments. This 2-year period lies within the five years before onset (20 March 2012 to 20 March 2017).

Factor 9(10)(g): for Crohn disease only: inability to undertake any physical activity greater than three METs for at least the five years before the clinical onset of Crohn disease; — MET

- After the hip fracture-dislocation and foot crush injury of 14 February 2012 an exercise physiologist assessed her maximum tolerated activity at 2.5 METs, limited by pain and gait, and this restriction was recorded at every annual review to 2017. She was unable to undertake physical activity greater than three METs from February 2012 to the onset on 20 March 2017, more than five years, including during her deployment to Iraq, where she worked at a desk.

Factor 9(10)(h): for Crohn disease only: being obese for at least five years within the 20 years before the clinical onset of Crohn disease; — MET

- The veteran's BMI was 30 or more from 15 January 2009 (BMI 31.2) on patrol boat service, rising to 35.8 after her 2012 injury, and remained above 30 to the onset on 20 March 2017, a period of 8 years within the 20 years before onset.

Factor 9(11): for ulcerative colitis only, in a person with a prior history of a regular smoking habit as specified, permanently ceasing to smoke between one and 20 years before the clinical onset of ulcerative colitis; — MET

- The veteran had a regular smoking habit of 15 cigarettes a day for 15 years, heavier at sea and on her 2007 warlike deployment, and permanently stopped on 01 March 2015. The colitis met the criteria for ulcerative colitis at onset on 20 March 2017, 2 years after she stopped, between one and 20 years.

Worsening factors

Factor 9(12): taking a drug from the Specified List 2 of drugs for at least the seven days before the clinical worsening of inflammatory bowel disease; — MET

- From 15 October 2018, during warlike service in the Middle East, the veteran took naproxen 500 mg twice daily, a drug from the Specified List 2, for post-traumatic hip pain, continuing through the seven days before the worsening from 05 November 2018 to 12 November 2018.

Factor 9(13): taking an immune checkpoint inhibitor within the one year before the clinical worsening of inflammatory bowel disease; — MET

- Nivolumab, an immune checkpoint inhibitor, was given from 04 December 2017 to 28 May 2018 for recurrent melanoma, within the one year before the worsening on 12 November 2018, which occurred on warlike service.

Factor 9(14): taking a combined oral contraceptive pill for a continuous period of at least six months before the clinical worsening of inflammatory bowel disease and where taking the combined oral contraceptive pill has ceased, the clinical worsening of inflammatory bowel disease has occurred within one year of cessation; — MET

- The combined oral contraceptive pill, taken continuously from 2003 for menstrual suppression during service, was ongoing during her 2018 warlike deployment and at the worsening on 12 November 2018.

Factor 9(15): undergoing organ or tissue transplantation, excluding corneal transplant, before the clinical worsening of inflammatory bowel disease; — MET

- The allograft tissue transplantation of 03 April 2012 took place before the worsening on 12 November 2018.

Factor 9(16): having a bowel infection within the 30 days before the clinical worsening of inflammatory bowel disease; — MET

- On 25 October 2018, during warlike service in the Middle East, the veteran developed acute gastroenteritis after a meal at the base dining facility, and stool culture grew Campylobacter jejuni. This bowel infection occurred 18 days before the worsening on 12 November 2018, within the 30 days before it.

Factor 9(17): experiencing a category 1A stressor within the three months before the clinical worsening of inflammatory bowel disease; — MET

- On 30 September 2018, during warlike service in the Middle East, a rocket struck the accommodation block next to hers, killing two coalition personnel and blowing in her windows. This life-threatening event occurred 43 days before the worsening, within the three months before it.

Factor 9(18): experiencing a category 1B stressor within the three months before the clinical worsening of inflammatory bowel disease; — MET

- On 15 October 2018, during warlike service, the veteran saw two critically injured soldiers at a vehicle rollover, one of whom died in front of her. This occurred 28 days before the worsening, within the three months before it.

Factor 9(19): experiencing a category 2 stressor within the 30 days before the clinical worsening of inflammatory bowel disease; — MET

- On 20 October 2018, while on warlike service, she was served with divorce papers and learned her husband was seeking sole custody of their child, with marked distress recorded by the deployed psychologist. This category 2 stressor occurred 23 days before the worsening, within the 30 days before it.

Factor 9(20): having a clinically significant depressive disorder or a clinically significant anxiety disorder for at least the one year before the clinical worsening of inflammatory bowel disease; — MET

- Major depressive disorder, diagnosed on 10 February 2013, remained clinically significant and continuous, with a PHQ-9 of 21 in September 2018, throughout the one year before the worsening, from 12 November 2017 to 12 November 2018, and worsened on her 2018 warlike deployment.

Factor 9(21)(a): for Crohn disease only: having smoked at least one pack-year of tobacco products before the clinical worsening of Crohn disease, and where smoking has permanently ceased, the clinical worsening of Crohn disease has occurred within four years of cessation; — MET

- The veteran smoked about 11 pack-years and permanently ceased on 01 March 2015. The worsening on 12 November 2018, on warlike service, occurred 3 years and 8 months after cessation, within four years.

Factor 9(21)(b): for Crohn disease only: where exposure to second-hand smoke has not permanently ceased: (i) being exposed to second-hand smoke for at least 5,000 hours before the clinical worsening of Crohn disease; and (ii) the first exposure to second-hand smoke commenced at least one year before the clinical worsening of Crohn disease; — MET

- Exposure to second-hand smoke in the designated smoking area beside her office and in shared accommodation continued during her 2018 warlike deployment and had not permanently ceased at the worsening. Her total exposure exceeded 5,000 hours before the worsening, and the first exposure began in February 2000.

Factor 9(21)(c): for Crohn disease only: where exposure to second-hand smoke has permanently ceased before the clinical worsening of Crohn disease: (i) being exposed to second-hand smoke for at least 5,000 hours; and (ii) the first exposure to second-hand smoke commenced at least one year before the clinical worsening of Crohn disease; and (iii) the clinical worsening of Crohn disease occurs within four years of the last exposure to second-hand smoke; — MET

- The veteran's shipboard second-hand smoke exposure of about 5,400 hours, from February 2000 to its permanent cessation on 30 June 2015, began more than one year before the worsening, and the worsening on 12 November 2018 occurred 3 years and 4 months after the last shipboard exposure, within four years.

Factor 9(21)(d): for Crohn disease only: an inability to undertake any physical activity greater than three METs for at least the five years before the clinical worsening of Crohn disease; — MET

- The veteran was unable to undertake physical activity greater than three METs from February 2012, because of her service hip and foot injuries, to the worsening on 12 November 2018, more than five years, as recorded by her exercise physiologist.

Factor 9(22): for ulcerative colitis only, in a person with a prior history of a regular smoking habit as specified, permanently ceasing to smoke between one and 20 years before the clinical worsening of ulcerative colitis; — MET

- The veteran had a regular smoking habit of 15 cigarettes a day for 15 years and permanently stopped on 01 March 2015. The worsening on 12 November 2018 occurred 3 years and 8 months after she stopped, between one and 20 years.

Factor 9(23): inability to obtain appropriate clinical management for inflammatory bowel disease; — MET

- After onset on warlike service in Iraq in March 2017 the veteran waited six weeks for colonoscopy, with no gastroenterologist in theatre. In 2018 she was redeployed with a disease only partly controlled on mesalazine, the azathioprine her gastroenterologist recommended was deferred because blood monitoring was unavailable in theatre, and when the disease flared in November 2018 she waited four days for aeromedical evacuation.

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

Sequelae

The inflammatory bowel disease has resulted in iron deficiency anaemia, faecal urgency with episodes of incontinence, weight loss and fatigue, and it has aggravated the veteran's depressive disorder. Long-term immunosuppression with infliximab and azathioprine increases her risk of serious infection and skin cancer, which is particularly relevant given her melanoma. These are sequelae of the accepted condition.

Unintended Consequence

Met. Pembrolizumab, nivolumab and peginterferon alfa-2b for melanoma, and long-term naproxen for her service hip and foot injuries, were prescribed and paid for by the Commonwealth, and each is a recognised cause of immune-mediated colitis or of flares of inflammatory bowel disease. The onset and the worsening of the disease are in part unintended consequences of that treatment (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. After the onset on warlike service in Iraq in March 2017 the veteran waited six weeks for colonoscopy because no gastroenterologist or endoscopy was available in theatre. In 2018 she was redeployed with partly controlled disease, the azathioprine her gastroenterologist had recommended was deferred because blood monitoring was not available in theatre, and when she flared severely in November 2018 she waited four days for aeromedical evacuation. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), investigation and treatment that were unavailable or deferred because of operational circumstances amount to an inability to obtain appropriate clinical management.

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

See attached report.

References

1. 14 Feb 2012, Admission record and operation report, Orthopaedic surgeon
2. 18 Jun 2012, Dietetic assessment, Dietitian
3. 10 Feb 2013, Psychiatric assessment, Consultant psychiatrist
4. 10 Jan 2016, Histopathology and specialist letters, Dermatologist and Medical oncologist
5. 20 Oct 2016, Pre-deployment health assessment, Medical Officer
6. 27 Mar 2017, Role 2 consultation and pathology, Medical Officer, Iraq
7. 05 May 2017, Colonoscopy and histopathology report, Gastroenterologist
8. 04 Dec 2017, Oncology treatment record, Medical oncologist
9. 25 Oct 2018, Medical record and stool culture, Medical Officer, Middle East
10. 12 Nov 2018, Medical record and aeromedical evacuation record, Medical Officer, Middle East
11. 20 Nov 2018, Hospital admission and CT report, Gastroenterologist
12. 22 Jan 2019, Ileocolonoscopy and histopathology report, Gastroenterologist
13. 30 Jan 2019, MR enterography, Radiologist
14. Statement of Principles concerning Inflammatory Bowel Disease (Balance of Probabilities) No. 91 of 2020, Repatriation Medical Authority
15. Statement of Principles concerning Inflammatory Bowel Disease (Reasonable Hypothesis) No. 90 of 2020, Repatriation Medical Authority