Liver - Elevated Liver Function Tests — DVA claim example (Diagnostic Assessment)

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Liver - Elevated Liver Function Tests

Example 1 of 1 · fictitious patient (Veteran D)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

Liver - Elevated Liver Function Tests

There is no Statement of Principles (SOP) for Liver - Elevated Liver Function Tests under either the Balance of Probabilities or Reasonable Hypothesis standards.

ADF History

The veteran, Airfield Defence Guard, enlisted 29 July 1993, currently serving.

Occupational History

As an Airfield Defence Guard (ADG) in the Royal Australian Air Force, the veteran would have been exposed to a range of occupational hazards inherent to the role. Chemical exposures could include fuels, oils, solvents, and cleaning agents associated with weapons and vehicle maintenance. The Post Deployment Health Screen for an operational deployment notes potential exposure to diesel exhaust fumes and fuels (aviation, marine or automotive) as daily above normal duty levels due to active airfield vehicles/plant and aircraft conducting engine running on/offloads.

History

The veteran an Airfield Defence Guard in the RAAF, has experienced episodes of elevated liver function tests. The first documented occurrence was in September 2001, associated with post-operative constipation and analgesic use following right ACL reconstruction. A subsequent note of altered liver function tests was documented in Mar 2020.

Timeline

29 July 1999. The veteran was admitted to 2HSB (and subsequently transferred to Mater Hospital A&E) with persistent abdominal pain due to constipation following his right ACL reconstruction on 24 July 1999. Blood tests showed elevated liver function tests: AST 69H U/L (range 10-45), ALT 159H U/L (range 5-45), GGT 300H U/L (range 10-70), ALP 170H U/L (range 40-110), and Total Bilirubin 21H umol/L (range <20). These abnormalities were documented in the context of post-operative constipation and analgesic use.
25 Jan 2018. During a consultation for low mood, it was noted that blood results showed altered LFTs. He was advised to repeat these tests. The medical record specifically notes that the veteran denied excess alcohol consumption at this time.

Symptoms

In September 2001, the veteran did not present with specific symptoms related to liver dysfunction. The elevated liver function tests were discovered incidentally during investigations for post-operative abdominal pain and constipation following right knee surgery. The symptoms that prompted medical attention were primarily gastrointestinal - persistent abdominal pain and lack of bowel movements for several days despite aperients.

In Mar 2020, there were no documented symptoms specifically attributable to liver dysfunction. The altered liver function tests were again discovered incidentally during investigations for another condition (low mood).

Currently, there are no documented ongoing symptoms specifically related to liver dysfunction.

Imaging

No specific liver imaging studies are documented in the available records.

1. What is the formal diagnosis of the condition claimed above? Liver - Elevated Liver Function Tests (R74.8 - Abnormal levels of other serum enzymes)

Elevated liver function tests (LFTs) represent biochemical abnormalities that indicate potential liver cell injury or dysfunction. These tests typically measure several enzymes and proteins including alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), and bilirubin.

Elevated LFTs are not a disease in themselves but rather indicate underlying liver pathology or systemic conditions affecting liver function. Transient elevations may occur due to medication effects, alcohol consumption, viral infections, or as a response to systemic illness or inflammation. Persistent elevations typically warrant further investigation to determine the underlying cause, which could include hepatitis, fatty liver disease, alcoholic liver disease, drug-induced liver injury, or other hepatobiliary disorders.

In this case, the veteran has had documented episodes of elevated liver function tests at two distinct time points. The first episode in 2003 occurred in the context of post-operative analgesic use, which is a well-recognized cause of transient liver enzyme elevations. The second episode in 2022 was noted without a clear attributable cause documented, though alcohol excess was specifically excluded.

These episodes appear to be temporally separate with no documentation of persistent elevation between these time points, suggesting transient rather than chronic liver dysfunction.

2. For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition? The veteran did not experience specific symptoms attributable to elevated liver function tests. The abnormalities were discovered incidentally during investigations for other conditions. The first documented elevation was on 29 July 1999 in the context of post-operative constipation following knee surgery.

When did the veteran first present to a health / medical provider for this condition? The veteran did not specifically present for evaluation of liver function. The first documented elevation of liver function tests occurred on 29 July 1999 when he was admitted to 2HSB and subsequently transferred to Mater Hospital A&E for post-operative constipation. The elevated liver function tests were discovered during this admission.

When was the condition confirmed / formally diagnosed? The elevated liver function tests were first documented on 29 July 1999 based on blood tests performed during his admission for post-operative constipation. The specific healthcare provider who ordered or interpreted these tests is not clearly identified in the available records. A subsequent notation of altered liver function tests was made on 25 Jan 2018.

When did the veteran first present to you (or your practice) for this condition? 26 Apr 2018

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 of elevated liver function tests was confirmed through standard biochemical blood tests. On 29 July 1999, the following abnormalities were documented:

AST: 69 U/L (elevated above reference range of 10-45 U/L)
ALT: 159 U/L (elevated above reference range of 5-45 U/L)
GGT: 300 U/L (elevated above reference range of 10-70 U/L)
ALP: 170 U/L (elevated above reference range of 40-110 U/L)
Total Bilirubin: 21 umol/L (elevated above reference range of <20 umol/L)

These abnormalities were noted in the context of post-operative constipation and analgesic use following right ACL reconstruction. There were no specific physical examination findings documented that would suggest clinically apparent liver disease (such as jaundice, hepatomegaly, or stigmata of chronic liver disease).

On 25 Jan 2018, altered liver function tests were again noted, though the specific values were not detailed in the available records. The note specifically mentioned that the veteran denied excess alcohol consumption.

No specific specialist opinions regarding these liver function abnormalities are documented in the available records, suggesting they were managed conservatively or considered incidental findings related to known causes (analgesic use, post-operative state).

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.

As there is no Statement of Principles for Elevated Liver Function Tests, I will consider general medical causation factors based on the available evidence:

Medication-induced liver injury

MET
The elevated liver function tests documented in September 2001 occurred in the context of post-operative analgesic use following ACL reconstruction surgery. The medical records specifically note that the veteran received Pethidine, Panadeine Forte (Codeine/Paracetamol), and other analgesics post-operatively. Many analgesics, particularly paracetamol/acetaminophen (a component of Panadeine Forte), are metabolized by the liver and can cause transient elevations in liver enzymes or, in higher doses, hepatotoxicity.

Alcohol consumption

NOT MET
While alcohol is a common cause of elevated liver function tests, the medical records consistently document low to moderate alcohol consumption throughout the veteran service. Specifically, in Mar 2020 when altered LFTs were noted, the record explicitly states that he denied excess alcohol consumption. Previous health assessments documented alcohol intake as "within low risk limits" (August 2001), "Sometimes 2 a week" (September 1999), and "Two to three times a week" with "One or two" drinks on a typical day (August 1998).

Metabolic factors (including obesity, dyslipidemia, diabetes)

NOT MET
The veteran BMI has generally been in the normal to overweight range (maximum recorded BMI was 25.7 in June 2000), but not in the obese range. There is no documentation of diabetes or significant dyslipidemia in the available records.

Exposure to hepatotoxic chemicals

POSSIBLY MET
As an Airfield Defence Guard, the veteran may have been exposed to potential hepatotoxins including fuels, oils, solvents, and cleaning agents. The Post Deployment Health Screen for an operational deployment specifically notes daily exposure above normal duty levels to "Fuels (aviation, marine or automotive)" and "Exposure to diesel exhaust fumes." However, a direct causal relationship between these exposures and his elevated liver function tests cannot be definitively established based on the available information.

Inability to obtain appropriate clinical management

NOT MET
The medical records indicate that the veteran received appropriate medical attention when elevated liver function tests were discovered. The Full Federal Court in Brew v Repatriation Commission (14 May 1993) enlarges on the meaning of "inability" as the lack of ability to get treatment in both an objective and subjective sense. There is no evidence in the available records suggesting that the veteran was unable to obtain appropriate clinical management for his elevated liver function tests.

The % contribution of the causes is 100% and significant

Sequelae

There is no evidence in the available records to suggest that the elevated liver function tests represent a sequelae of another condition. The first documented elevation in 2003 appears to be related to post-operative analgesic use, which is a direct effect rather than a sequelae. The cause of the 2022 elevation is not clearly documented.

Unintended Consequence

The elevated liver function tests documented in September 2001 could be considered an unintended consequence of medical management, specifically the administration of analgesics following ACL reconstruction surgery. Many analgesics, particularly those containing paracetamol/acetaminophen, are known to potentially cause transient liver enzyme elevations as a side effect.

As per section 20.1 of the MRCA - Unintended Consequences of Medical Treatment, compensation is payable if a member receives medical treatment paid for by the Commonwealth and suffers an injury as an unintended consequence of that treatment. This applies whether or not the original condition being treated was compensable under the Act.

In this case, the veteran received analgesics as part of his post-operative care following ACL reconstruction, which was a treatment paid for by the Commonwealth. The elevated liver enzymes that followed could be considered an unintended consequence of this treatment.

Inability to Attain Appropriate Medical Management

There is no evidence in the available records to suggest an inability to attain appropriate medical management for elevated liver function tests. When abnormalities were detected in September 2001 and Mar 2020, they were appropriately documented, and in the 2022 instance, repeat testing was advised.

The Full Federal Court in Brew v Repatriation Commission (14 May 1993) (see the judgement of Merkel J) enlarges on the meaning to be given to "inability" as the lack of the ability to get the treatment in both an objective and subjective sense. Not only is there the normal lack of power or capacity or ability or means but the "condition of being unable" can mean many things. Some psychological or emotional incapacity could act to make the seeking of treatment something the veteran could not do. Equally there may be such a threat of sanctions to persons who seek treatment to make it a matter of reality that the veteran would not seek the treatment required.

In this case, there is no indication of objective barriers to healthcare access or subjective factors that would have prevented the veteran from seeking appropriate care. The medical records demonstrate that he had regular access to healthcare services throughout his service.

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

Need a Diagnostic Assessment like this written from your own medical record? A VHC Chart Review finds every claimable condition in your file, and each one is written up against its Statement of Principles. Fixed fee $600 + GST per stage — see all fees or book an appointment.