Diagnostic Assessment — Peritoneal Adhesions
Example 1 of 1 · fictitious patient (Veteran CI)
Diagnostic Assessment
Peritoneal Adhesions
BOP Code: 10 of 2025 (Peritoneal Adhesions)
RH Code: 9 of 2025 (Peritoneal Adhesions)
ADF History
Veteran CI, date of birth 03 June 1950, Australian Army, Nursing Officer (Royal Australian Army Nursing Corps), enlisted 12 January 1970, medically discharged 30 June 2008. Operational service: South Vietnam, 10 February 1971 to 15 November 1971 (warlike); East Timor, 22 September 1999 to 20 March 2000 (warlike); Bougainville, 15 January 2002 to 30 June 2002 (non-warlike); Solomon Islands, 24 July 2003 to 20 December 2003 (non-warlike).
Occupational History
As a nursing officer the veteran worked in field and garrison hospitals, surgical teams and primary health facilities, often on long shifts and in austere conditions on operations. Duties included the care of surgical, trauma and infectious patients and, in later years, the command and administration of deployed health facilities.
Deployed health personnel are exposed to tropical and gastrointestinal infections, sexually transmitted infection in the era of the Vietnam War, blood-borne pathogens, occupational injury and, in conflict zones, hostile fire and fragmentation injury. Access to definitive surgical and specialist care on operations is limited and delayed by evacuation chains.
History
Veteran CI, an Army nursing officer, developed symptomatic peritoneal adhesions with encapsulating peritoneal sclerosis, presenting as adhesive small bowel obstruction on 14 July 2007. The adhesions followed a penetrating fragment wound to the abdomen with bowel perforation and peritonitis on warlike service in East Timor in 1999, multiple subsequent abdominal operations, pelvic infection and endometriosis, a ruptured ovarian dermoid cyst, abdominal radiotherapy and intraperitoneal chemotherapy for rectal cancer with peritoneal spread, peritoneal dialysis, shunts, practolol taken in Vietnam and peritoneal sarcoidosis.
Timeline
- 20 Sep 1971 — On warlike service in South Vietnam the veteran, who had been treated at the field hospital in August 1971 for acute pelvic inflammatory disease (gonococcal and chlamydial salpingitis) and had recurrent severe dysmenorrhoea and pelvic pain from July 1971, presented with recurrent palpitations. Paroxysmal supraventricular tachycardia was confirmed on ECG and a physician commenced practolol 100 mg twice daily. She continued practolol without interruption until 14 November 1972, when it was ceased because of reports of oculomucocutaneous and peritoneal side effects. "PSVT, practolol 100 mg bd"
- 12 Mar 1979 — Laparoscopy for chronic pelvic pain and dysmenorrhoea, present since her service in Vietnam, showed stage III endometriosis with deposits on the uterosacral ligaments, pouch of Douglas and left ovary, and fine pelvic adhesions consistent with previous pelvic inflammatory disease. Endometriotic deposits were ablated and danazol was commenced. Endometriosis remained active with further treatment until menopause. "stage III endometriosis, pelvic adhesions"
- 18 Dec 1999 — On warlike service in East Timor the veteran was struck in the left abdomen by a grenade fragment during an attack near a forward clinic. A forward surgical team performed an emergency laparotomy and found two perforations of the jejunum and gross faecal and enteric contamination of the peritoneal cavity. The perforations were repaired and the abdomen washed out. Peritoneal fluid grew Escherichia coli, Bacteroides fragilis and Candida albicans, and she was treated for generalised bacterial and fungal peritonitis before evacuation to Australia. "penetrating fragment, jejunal perforations, peritonitis"
- 10 Mar 2002 — On non-warlike service in Bougainville the veteran developed acute appendicitis and underwent appendicectomy after evacuation to a regional hospital. On 22 May 2002, still on deployment, she developed acute calculous cholecystitis with gallstone pancreatitis (lipase more than ten times normal) and was treated conservatively before evacuation. In December 2001 pulmonary sarcoidosis had been diagnosed on bronchoscopic biopsy. "appendicectomy; cholecystitis with pancreatitis"
- 22 Sep 2003 — On non-warlike service in the Solomon Islands the veteran presented with sudden severe lower abdominal pain. At laparotomy a mature cystic teratoma (dermoid cyst) of the right ovary had ruptured into the peritoneal cavity, with sebaceous material and hair causing chemical peritonitis. The cyst was excised and the peritoneum lavaged. In October 2003 she developed bloody diarrhoea later shown to be Crohn's disease, and in November 2003 pneumococcal meningitis, complicated by communicating hydrocephalus treated with a ventriculoperitoneal shunt on 11 February 2004. "ruptured dermoid, chemical peritonitis"
- 16 Feb 2005 — A general surgeon repaired a large incisional hernia at the site of the 1999 laparotomy wound with a polypropylene mesh placed in the abdominal wall. A retained surgical sponge, seen on CT in October 2004 as a radio-opaque marker in the left upper abdomen, was removed at the same operation from beneath the old wound. Laparoscopic cholecystectomy had been performed in December 2004. Crohn's terminal ileitis had been confirmed at colonoscopy in March 2004 and an episode of sigmoid diverticulitis on CT in July 2004. "mesh repair, retained sponge removed"
- 21 Aug 2006 — Rectal adenocarcinoma had been diagnosed in June 2005 and treated with a radical course of pelvic chemoradiotherapy (50.4 Gy in 28 fractions) and anterior resection. Peritoneal metastases were found in June 2006, and on this date she underwent cytoreductive surgery with hyperthermic intraperitoneal chemotherapy using mitomycin C. Post-operatively she developed mitomycin-associated renal failure and began peritoneal dialysis on 02 October 2006, continuing until 30 April 2007. "cytoreduction and intraperitoneal mitomycin C"
- 14 May 2007 — Because of ultrafiltration failure and refractory ascites, peritoneal dialysis was replaced by haemodialysis on 30 April 2007, and on 14 May 2007 an interventional radiologist inserted a peritoneovenous shunt to control the ascites. The ventriculoperitoneal shunt remained in place. "peritoneovenous shunt for ascites"
- 18 Jul 2007 — The veteran presented on 14 July 2007 with colicky abdominal pain, distension and vomiting. CT showed small bowel obstruction with a thickened, encasing peritoneal membrane. At laparotomy on 18 July 2007 the surgeon found dense adhesions throughout the abdomen and pelvis and a fibrous cocoon encasing the small bowel, typical of encapsulating peritoneal sclerosis, and performed adhesiolysis and membrane stripping. Peritoneal biopsies showed fibrosis and non-caseating granulomas consistent with peritoneal sarcoidosis. "dense adhesions, encapsulating peritoneal sclerosis"
Symptoms
At onset the veteran had colicky central abdominal pain, abdominal distension, vomiting and absolute constipation, consistent with small bowel obstruction, after several weeks of post-prandial bloating and intermittent pain.
Since the adhesiolysis she has had recurrent episodes of subacute obstruction, chronic abdominal pain, early satiety, weight loss and altered bowel habit, requiring a low-residue diet. A further admission for adhesive obstruction in March 2008 was managed conservatively, and she was medically discharged in June 2008.
Imaging
- 18 Dec 1999 — Abdominal radiograph (forward surgical team): "Metallic fragment in the left upper quadrant. Free intraperitoneal gas."
- 12 Oct 2004 — CT abdomen and pelvis: "Radio-opaque surgical sponge marker in the left upper quadrant deep to the old laparotomy scar. Large incisional hernia. Terminal ileal wall thickening consistent with Crohn's disease. Ventriculoperitoneal shunt tip in the pelvis."
- 09 Jun 2006 — PET-CT: "Nodular peritoneal deposits in the omentum and pelvis consistent with peritoneal metastases."
- 14 Jul 2007 — CT abdomen and pelvis: "Small bowel obstruction with clustering of small bowel loops encased by a thickened, enhancing peritoneal membrane, consistent with encapsulating peritoneal sclerosis and adhesions."
Onset Date
The most likely date of onset of this condition is 14 Jul 2007.
At that date the veteran was a serving nursing officer in a non-deployable staff appointment in Australia, receiving haemodialysis and oncology follow-up. She developed colicky abdominal pain, distension and vomiting on that day and presented to hospital.
This date is appropriate because CT on 09 June 2006 and the findings at the cytoreductive operation on 21 August 2006 recorded no encapsulating membrane and only limited adhesions, and her first presentation with obstruction was on 14 July 2007, with the adhesions and encapsulating peritoneal sclerosis confirmed at laparotomy on 18 July 2007. The onset falls within continuous full-time service.
Most factors in this Statement of Principles require the event to have occurred at least 3 days before onset, that is, before 11 Jul 2007. The peritonitis, perforation, penetrating trauma and infection of 18 Dec 1999, the abdominal operations from 1999 to 2006, the pelvic inflammatory disease of 1971, the endometriosis of 1979, the appendicitis, cholecystitis and pancreatitis of 2002, the ruptured dermoid of 2003, the Crohn's disease and diverticulitis of 2004, the retained sponge, the mesh of 2005, the radiotherapy of 2005, the peritoneal metastases and intraperitoneal chemotherapy of 2006, the ventriculoperitoneal shunt of 2004 and the peritoneovenous shunt of 14 May 2007 all preceded 11 Jul 2007. For the peritoneal dialysis factor, the dialysis ran from 02 Oct 2006 to 30 Apr 2007, almost seven months before onset. For the practolol factor, she took practolol for 14 months, from 20 Sep 1971 to 14 Nov 1972. Peritoneal sarcoidosis was present at onset, confirmed on biopsy on 18 Jul 2007.
This Statement of Principles contains no worsening factors. The condition worsened after onset, with a further admission for adhesive small bowel obstruction on 11 Mar 2008, and that worsening forms part of the accepted condition.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Peritoneal Adhesions (ICD-10-AM K66.0), including encapsulating peritoneal sclerosis, under the Statements of Principles concerning peritoneal adhesions, Balance of Probabilities No. 10 of 2025 and Reasonable Hypothesis No. 9 of 2025.
Peritoneal adhesions are bands of fibrous tissue between abdominal organs, or between organs and the parietal peritoneum, resulting from an abnormal inflammatory reaction of the peritoneum. They form after surgery, infection, inflammation, trauma, radiation and chemical injury of the peritoneum. Encapsulating peritoneal sclerosis is a severe form in which a thick fibrous membrane encases the small bowel, classically associated with long-term peritoneal dialysis, peritoneovenous shunts and practolol. Adhesions cause small bowel obstruction, chronic abdominal pain, infertility and difficulty with later surgery.
The condition became clinically apparent on 14 July 2007, was confirmed at laparotomy on 18 July 2007 and has since caused recurrent obstruction.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
14 July 2007.
When did the veteran first present to a health / medical provider for this condition?
14 July 2007.
When was the condition confirmed / formally diagnosed?
18 July 2007.
When did the veteran first present to you (or your practice) for this condition?
05 February 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed at laparotomy on 18 July 2007, where the surgeon found dense fibrous adhesions between small bowel loops, the omentum and the parietal peritoneum and a fibrous membrane encasing the small bowel. These are abnormal fibrous bands resulting from an inflammatory reaction of the peritoneum and include encapsulating peritoneal sclerosis, meeting the Statement of Principles definition of peritoneal adhesions. They were acquired, not congenital.
The preceding CT of 14 July 2007 showed small bowel obstruction with clustered loops encased by a thickened peritoneal membrane. Histopathology confirmed peritoneal fibrosis with non-caseating granulomas.
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 14 July 2007, 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 South Vietnam in 1971 and East Timor in 1999 and 2000, and her non-warlike service in Bougainville in 2002 and the Solomon Islands in 2003, during which the principal causative events occurred.
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 Peritoneal Adhesions, No. 10 of 2025
Causative factors
Factor 9(1): having peritonitis at least 3 days before clinical onset; — MET
- Generalised bacterial and fungal peritonitis was confirmed at the laparotomy of 18 December 1999, with Escherichia coli, Bacteroides fragilis and Candida albicans cultured from the peritoneal fluid after the service-related fragment wound. A chemical peritonitis followed the dermoid rupture of 22 September 2003. Both occurred many years before the onset on 14 July 2007.
Factor 9(2)(a): having one of the following diseases at least 3 days before clinical onset: appendicitis; — MET
- The veteran had acute appendicitis on 10 March 2002, confirmed at appendicectomy and on histopathology, more than five years before onset. It occurred during her service.
Factor 9(2)(b): having one of the following diseases at least 3 days before clinical onset: cholecystitis; — MET
- Acute calculous cholecystitis was diagnosed on 22 May 2002 on ultrasound and treated, followed by laparoscopic cholecystectomy in December 2004, years before onset. It occurred during her service.
Factor 9(2)(c): having one of the following diseases at least 3 days before clinical onset: diverticulitis; — MET
- Sigmoid diverticulitis was confirmed on CT in July 2004 and treated with antibiotics, three years before onset, while she was serving.
Factor 9(2)(d): having one of the following diseases at least 3 days before clinical onset: endometriosis; — MET
- Stage III endometriosis was confirmed at laparoscopy on 12 March 1979, with pelvic deposits and adhesions, and remained active until menopause. Symptoms had begun during service in 1971.
Factor 9(2)(e): having one of the following diseases at least 3 days before clinical onset: inflammatory bowel disease; — MET
- Crohn's disease of the terminal ileum, an inflammatory bowel disease, was confirmed on colonoscopy and biopsy in March 2004 and was present for three years before onset. Symptoms began during service in October 2003.
Factor 9(2)(f): having one of the following diseases at least 3 days before clinical onset: pancreatitis; — MET
- Acute gallstone pancreatitis, with lipase more than ten times the upper limit of normal, was diagnosed on 22 May 2002 during her service, more than five years before onset.
Factor 9(2)(g): having one of the following diseases at least 3 days before clinical onset: pelvic inflammatory disease. — MET
- Acute pelvic inflammatory disease due to gonococcal and chlamydial salpingitis was treated at the field hospital in August 1971 during her service, and fine pelvic adhesions consistent with it were seen at laparoscopy in 1979.
Factor 9(3): having intra-abdominal or pelvic surgery at least 3 days before clinical onset; — MET
- The veteran had multiple intra-abdominal and pelvic operations before onset: laparotomy on 18 December 1999, appendicectomy on 10 March 2002, laparotomy for the ruptured dermoid on 22 September 2003, ventriculoperitoneal shunt insertion on 11 February 2004, cholecystectomy in December 2004, hernia repair with sponge removal on 16 February 2005, anterior resection in November 2005 and cytoreductive surgery on 21 August 2006. All preceded the onset on 14 July 2007 by far more than 3 days and arose from conditions related to her service.
Factor 9(4): having penetrating trauma to the abdomen that enters the peritoneal cavity at least 3 days before clinical onset; — MET
- On 18 December 1999 a grenade fragment penetrated the veteran's left abdominal wall and entered the peritoneal cavity, perforating the jejunum in two places, confirmed at laparotomy. It occurred in the course of her service, more than seven years before onset.
Factor 9(5): undergoing a course of ablative radiotherapy for cancer, where the abdominopelvic region was in the field of radiation, at least 3 days before clinical onset; — MET
- Between June and August 2005 the veteran underwent a radical (ablative) course of chemoradiotherapy for rectal adenocarcinoma, 50.4 Gy in 28 fractions with the pelvis and lower abdomen in the field of radiation, nearly two years before onset. The cancer arose while she was serving.
Factor 9(6): having a bacterial, fungal or Echinococcus granulosus infection involving the peritoneal cavity at least 3 days before clinical onset; — MET
- Bacterial infection of the peritoneal cavity with Escherichia coli and Bacteroides fragilis, and fungal infection with Candida albicans, were cultured from peritoneal fluid at the laparotomy of 18 December 1999, following the service-related fragment wound.
Factor 9(7): having a perforation of the hollow viscus into the peritoneal cavity at least 3 days before clinical onset; — MET
- The jejunum, a hollow viscus, was perforated into the peritoneal cavity in two places by the fragment wound of 18 December 1999, with gross enteric contamination, confirmed at laparotomy more than seven years before onset.
Factor 9(8): undergoing peritoneal dialysis for at least 6 months duration before clinical onset; — MET
- The veteran underwent peritoneal dialysis from 02 October 2006 to 30 April 2007, a duration of almost seven months, for renal failure caused by mitomycin C given as treatment for her cancer. The dialysis ended 75 days before the onset on 14 July 2007.
Factor 9(9): undergoing intraperitoneal chemotherapy with cisplatin, oxaliplatin, carboplatin, 5-fluorouracil, mitoxantrone (mitozantrone), or mitomycin C at least 3 days before clinical onset; — MET
- On 21 August 2006 the veteran received hyperthermic intraperitoneal chemotherapy with mitomycin C at cytoreductive surgery for peritoneal metastases, almost eleven months before onset.
Factor 9(10): having a primary or secondary malignant neoplasm involving the peritoneum at least 3 days before clinical onset; — MET
- Peritoneal metastases from rectal adenocarcinoma were shown on PET-CT on 09 June 2006 and confirmed histologically at cytoreductive surgery on 21 August 2006, more than 3 days before onset.
Factor 9(11): having an ovarian dermoid cyst rupturing into the peritoneum at least 3 days before clinical onset; — MET
- A mature cystic teratoma (dermoid cyst) of the right ovary ruptured into the peritoneal cavity on 22 September 2003, causing chemical peritonitis, confirmed at laparotomy and on histopathology, almost four years before onset.
Factor 9(12): having a ventriculoperitoneal shunt at least 3 days before clinical onset; — MET
- A ventriculoperitoneal shunt was inserted on 11 February 2004 for communicating hydrocephalus following pneumococcal meningitis contracted during service in 2003, and remained in place at onset, with the distal tip in the peritoneal cavity.
Factor 9(13): having hernia mesh inserted in the abdomen at the site of the subsequent peritoneal adhesions at least 3 days before clinical onset; — MET
- On 16 February 2005 a polypropylene hernia mesh was inserted at the site of the 1999 laparotomy wound, and at the laparotomy of 18 July 2007 dense adhesions were found between the small bowel and the abdominal wall at the mesh site. The hernia arose from the service-related laparotomy.
Factor 9(14): having a retained surgical sponge at least 3 days before clinical onset; — MET
- A surgical sponge was retained in the abdomen at the laparotomy of 18 December 1999, seen on CT on 12 October 2004 and removed on 16 February 2005, more than two years before onset. The adhesions at that site were densest at the 2007 laparotomy.
Factor 9(15): taking practolol for at least 1 year before clinical onset. — MET
- The veteran took practolol 100 mg twice daily from 20 September 1971 to 14 November 1972, a period of 14 months, prescribed by a military physician for paroxysmal supraventricular tachycardia that began during her service.
Reasonable Hypothesis — Statement of Principles concerning Peritoneal Adhesions, No. 9 of 2025
Causative factors
Factor 9(1): having peritonitis at least 3 days before clinical onset; — MET
- Generalised bacterial and fungal peritonitis followed the grenade fragment wound with jejunal perforation sustained on warlike service in East Timor on 18 December 1999, confirmed at laparotomy by the forward surgical team, more than seven years before onset.
Factor 9(2)(a): having one of the following diseases at least 3 days before clinical onset: appendicitis; — MET
- Acute appendicitis on non-warlike service in Bougainville on 10 March 2002 was confirmed at appendicectomy and on histopathology, more than five years before onset.
Factor 9(2)(b): having one of the following diseases at least 3 days before clinical onset: cholecystitis; — MET
- Acute calculous cholecystitis was diagnosed on ultrasound on non-warlike service in Bougainville on 22 May 2002 and required evacuation, more than five years before onset.
Factor 9(2)(c): having one of the following diseases at least 3 days before clinical onset: diverticulitis; — MET
- The first episode of sigmoid diverticulitis, with left iliac fossa pain and fever, was treated on non-warlike service in the Solomon Islands in December 2003 and confirmed on CT in July 2004, three years before onset.
Factor 9(2)(d): having one of the following diseases at least 3 days before clinical onset: endometriosis; — MET
- Endometriosis was confirmed at laparoscopy in 1979; its symptoms of severe dysmenorrhoea and pelvic pain began and were first recorded during warlike service in South Vietnam in July 1971, and the disease remained active for many years before onset.
Factor 9(2)(e): having one of the following diseases at least 3 days before clinical onset: inflammatory bowel disease; — MET
- Crohn's disease began with bloody diarrhoea on non-warlike service in the Solomon Islands in October 2003, initially treated as infective, and was confirmed at colonoscopy in March 2004, more than three years before onset.
Factor 9(2)(f): having one of the following diseases at least 3 days before clinical onset: pancreatitis; — MET
- Acute gallstone pancreatitis occurred on non-warlike service in Bougainville on 22 May 2002, confirmed by a lipase more than ten times normal, more than five years before onset.
Factor 9(2)(g): having one of the following diseases at least 3 days before clinical onset: pelvic inflammatory disease. — MET
- Acute pelvic inflammatory disease from gonococcal and chlamydial salpingitis was diagnosed and treated at the field hospital on warlike service in South Vietnam in August 1971, decades before onset.
Factor 9(3): having intra-abdominal or pelvic surgery at least 3 days before clinical onset; — MET
- The emergency laparotomy of 18 December 1999 on warlike service in East Timor, the appendicectomy of 10 March 2002 on non-warlike service in Bougainville and the laparotomy of 22 September 2003 on non-warlike service in the Solomon Islands were intra-abdominal operations performed on operational service, all years before onset. The later operations treated the consequences of these.
Factor 9(4): having penetrating trauma to the abdomen that enters the peritoneal cavity at least 3 days before clinical onset; — MET
- A grenade fragment penetrated the abdomen and entered the peritoneal cavity, perforating the jejunum, during an attack on warlike service in East Timor on 18 December 1999, more than seven years before onset.
Factor 9(5): undergoing a course of ablative radiotherapy for cancer, where the abdominopelvic region was in the field of radiation, at least 3 days before clinical onset; — MET
- The veteran underwent a radical (ablative) course of pelvic chemoradiotherapy, 50.4 Gy in 28 fractions with the abdominopelvic region in the field, for rectal adenocarcinoma in 2005. The cancer has been accepted as related to her service, which included warlike service in South Vietnam and East Timor, and the radiotherapy ended nearly two years before onset.
Factor 9(6): having a bacterial, fungal or Echinococcus granulosus infection involving the peritoneal cavity at least 3 days before clinical onset; — MET
- Escherichia coli, Bacteroides fragilis and Candida albicans infection of the peritoneal cavity followed the fragment wound and bowel perforation on warlike service in East Timor on 18 December 1999, confirmed on culture of peritoneal fluid.
Factor 9(7): having a perforation of the hollow viscus into the peritoneal cavity at least 3 days before clinical onset; — MET
- The jejunum was perforated into the peritoneal cavity in two places by the grenade fragment on warlike service in East Timor on 18 December 1999, confirmed at laparotomy.
Factor 9(8): undergoing peritoneal dialysis for at least 6 months duration before clinical onset; — MET
- The veteran received peritoneal dialysis from 02 October 2006 to 30 April 2007, almost seven months, for renal failure caused by intraperitoneal mitomycin C given for the accepted rectal cancer. The dialysis ended 75 days before onset.
Factor 9(9): undergoing intraperitoneal chemotherapy with cisplatin, oxaliplatin, carboplatin, 5-fluorouracil, mitoxantrone (mitozantrone), or mitomycin C at least 3 days before clinical onset; — MET
- Hyperthermic intraperitoneal chemotherapy with mitomycin C was given at cytoreductive surgery on 21 August 2006 for peritoneal spread of the accepted rectal cancer, almost eleven months before onset.
Factor 9(10): having a primary or secondary malignant neoplasm involving the peritoneum at least 3 days before clinical onset; — MET
- Secondary malignant neoplasm involving the peritoneum, from the accepted rectal adenocarcinoma, was confirmed at cytoreductive surgery on 21 August 2006, almost eleven months before onset.
Factor 9(11): having an ovarian dermoid cyst rupturing into the peritoneum at least 3 days before clinical onset; — MET
- A dermoid cyst of the right ovary ruptured into the peritoneum on non-warlike service in the Solomon Islands on 22 September 2003, confirmed at emergency laparotomy and on histopathology, almost four years before onset.
Factor 9(12): having a ventriculoperitoneal shunt at least 3 days before clinical onset; — MET
- A ventriculoperitoneal shunt was inserted on 11 February 2004 for hydrocephalus following pneumococcal meningitis contracted on non-warlike service in the Solomon Islands in November 2003, and it was in place for more than three years before onset.
Factor 9(13): having a peritoneovenous shunt at least 3 days before the clinical onset of encapsulating peritoneal sclerosis; — MET
- A peritoneovenous shunt was inserted on 14 May 2007 for refractory ascites, 61 days before the onset of encapsulating peritoneal sclerosis on 14 July 2007. The ascites resulted from peritoneal dialysis and peritoneal spread of the accepted cancer.
Factor 9(14): having hernia mesh inserted in the abdomen at the site of the subsequent peritoneal adhesions at least 3 days before clinical onset; — MET
- Hernia mesh was inserted on 16 February 2005 at the site of the laparotomy wound from warlike service in East Timor, where dense adhesions were later found at the 2007 laparotomy, more than two years before onset.
Factor 9(15): having a retained surgical sponge at least 3 days before clinical onset; — MET
- A surgical sponge was retained in the abdomen at the forward surgical team's laparotomy on warlike service in East Timor on 18 December 1999, and remained until its removal on 16 February 2005, more than two years before onset.
Factor 9(16): taking practolol for at least 1 year before clinical onset; — MET
- Practolol 100 mg twice daily was prescribed by a military physician on warlike service in South Vietnam from 20 September 1971 for paroxysmal supraventricular tachycardia, and was taken continuously for 14 months, until 14 November 1972.
Factor 9(17): having peritoneal sarcoidosis at the time of clinical onset. — MET
- Peritoneal biopsies taken at the laparotomy on 18 July 2007 showed non-caseating granulomas consistent with peritoneal sarcoidosis, present at the onset. Pulmonary sarcoidosis had been diagnosed in December 2001, after warlike service in East Timor where she was exposed to smoke from burning buildings and dust.
The % contribution of the causes is 100% and significant.
Sequelae
The peritoneal adhesions are a sequela of the veteran's service-related penetrating abdominal wound and peritonitis, the operations that followed it, and her other accepted abdominal and pelvic conditions and their treatment. The recurrent small bowel obstruction, chronic abdominal pain and nutritional impairment are sequelae of the adhesions.
Unintended Consequence
Met. The adhesions are in part an unintended consequence of medical treatment provided by the Commonwealth: the surgical sponge left in the abdomen at the 1999 laparotomy, the hernia mesh, the ventriculoperitoneal and peritoneovenous shunts, peritoneal dialysis, radiotherapy and intraperitoneal mitomycin C, and practolol prescribed by a military physician in Vietnam (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
Not applicable as a factor. This Statement of Principles contains no factor for inability to obtain appropriate clinical management. It is nonetheless relevant that on warlike service in East Timor in December 1999 definitive surgery was performed by a forward surgical team in austere conditions, where a surgical sponge was retained and the contaminated abdomen could not be managed with the planned second-look laparotomy until after evacuation. Applying the reasoning in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), these operational constraints on care contributed to the extent of the adhesions.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- Aug 1971 and 20 Sep 1971, Field hospital records and physician consultation, South Vietnam
- 14 Nov 1972, Cardiology review, Physician
- 12 Mar 1979, Operation report, Gynaecologist
- 18 Dec 1999, Operation report and microbiology, Forward surgical team, East Timor
- Dec 2001, Bronchoscopy and respiratory consultation, Respiratory physician
- 10 Mar 2002 and 22 May 2002, Hospital admission records, Bougainville
- 22 Sep 2003, Operation report and histopathology, Solomon Islands
- 11 Feb 2004, Operation report, Neurosurgeon
- Mar 2004, Colonoscopy and histopathology, Gastroenterologist
- 12 Oct 2004, CT abdomen and pelvis, Radiologist
- 16 Feb 2005, Operation report, General surgeon
- Jun 2005 to Nov 2005, Radiation oncology and colorectal surgery records
- 21 Aug 2006, Operation report, Peritoneal malignancy surgeon
- 02 Oct 2006 to 30 Apr 2007, Peritoneal dialysis records, Renal physician
- 14 May 2007, Procedure report, Interventional radiologist
- 18 Jul 2007, Operation report and histopathology, General surgeon
- Statement of Principles concerning Peritoneal Adhesions (Balance of Probabilities) No. 10 of 2025, Repatriation Medical Authority
- Statement of Principles concerning Peritoneal Adhesions (Reasonable Hypothesis) No. 9 of 2025, Repatriation Medical Authority
