Cholelithiasis

Reference Determination Content

Suggested draft · fictitious patient

Example document — fictitious patient. This is a suggested draft determination prepared by the Veterans Health Centre from the matching example Diagnostic Assessment, to show how a DVA delegate could determine the claim. The veteran is fictitious: names, dates, service details and clinicians have been invented. It is not a decision of the Department of Veterans' Affairs and must not be relied upon as a record of any real claim.

Evidence

The evidence that I have considered in making this decision includes:

Formal Claim with supporting statements;
A Statement of your Service from the Department of Defence;
Copies of your Service Medical Records.
A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 30 July 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 30 July 2025;
A field hospital incident record by the rwanda, and hepatitis serology September 1995, Pathologist, dated 14 May 1995;
An operation report and histology by the colorectal surgeon and pathologist, dated 22 March 2001;
An outpatient health record by the medical officer, Garrison health centre, dated 12 June 2007;
An ultrasound abdomen report and hepatology consultation by the radiologist and hepatologist, dated 3 September 2008;
An obstetric and haematology admission record by the obstetrician and haematologist, dated 14 January 2009;
A gastroenterology admission and parenteral nutrition record by the gastroenterologist, dated 8 June 2009;
An emergency department record and ultrasound abdomen report by the emergency physician and radiologist, dated 21 July 2009;
An aeromedical evacuation and spinal injury unit records by the spinal surgeon, dated 14 September 2011;
An operation report by the general surgeon, dated 26 October 2011;
A transient elastography and liver biopsy report by the hepatologist and pathologist, dated 18 May 2015;
An ERCP report (bile culture and haematology record) by the gastroenterologist and haematologist, dated 12 March 2016;
A hospital admission record by the MRCP and CT abdomen reports, General physician and Radiologist, dated 20 October 2016;
An ERCP report and bile PCR by the gastroenterologist and microbiologist, dated 24 October 2016;
An endoscopic ultrasound biopsy report by the gastroenterologist and pathologist, dated 27 October 2016;
An operation report by the hepatobiliary surgeon, dated 15 March 2017.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

15 January 1990 and 19 December 2013

Cholelithiasis

You have stated that your condition was caused by:

having a spinal cord injury at the time of clinical onset or clinical worsening
having a foreign body in the biliary tract, or a mechanical obstruction of the biliary tract, before clinical onset or clinical worsening
having an ileal resection or ileal bypass within the 25 years before clinical onset or clinical worsening
having a gastric or oesophageal resection, or another operation that includes a vagotomy, within the 5 years before clinical onset or clinical worsening
having one of the following parasitic diseases of the biliary tract at the time of clinical onset or clinical worsening: (a) ascariasis; (b) clonorchiasis; (c) fascioliasis; (d) opisthorchiasis
having Helicobacter pylori infection of the biliary tract at the time of clinical onset or clinical worsening
having cholangiohepatitis or recurrent pyogenic cholangitis at the time of clinical onset or clinical worsening
having an acquired haemolytic disease, characterised by red cell defects and breakdown with bilirubin overproduction, within the 1 year before clinical onset or clinical worsening
having worsening of an inherited haemolytic disease, characterised by red cell defects and breakdown with bilirubin overproduction, within the 1 year before clinical onset or clinical worsening
having a somatostatinoma at the time of clinical onset or clinical worsening
being pregnant within the 3 months before clinical onset or clinical worsening
for males, being obese for at least the 5 years before clinical onset or clinical worsening
for females, being overweight or obese for at least the 5 years before clinical onset or clinical worsening
having rapid and extreme weight loss, involving a reduction of body mass by at least 15 percent: (a) within a continuous 6 month period; or (b) at an average rate of at least 1.5 kilograms per week, and within the 1 year before clinical onset or clinical worsening
having a very low-calorie diet, with an energy intake of less than 800 kilocalories per day, for the 1 year before clinical onset or clinical worsening
having type 2 diabetes mellitus at the time of clinical onset or clinical worsening
having cirrhosis of the liver at the time of clinical onset or clinical worsening
having Crohn disease at the time of clinical onset or clinical worsening
taking any of the following medications for a continuous period of at least 6 months before clinical onset or clinical worsening, and where treatment has ceased, clinical onset or clinical worsening occurred within 3 months of cessation: (a) atazanavir; (b) cyclosporine A; (c) fibrates; (d) somatostatin analogues; (e) tamoxifen
having oestrogen therapy for a continuous period of at least 6 months before clinical onset or clinical worsening, and where oestrogen therapy has ceased, clinical onset or clinical worsening occurred within 3 months of cessation
having total parenteral nutrition for a continuous period of at least 3 weeks before clinical onset or clinical worsening, and where total parenteral nutrition has ceased, clinical onset or clinical worsening occurred within 30 days of cessation
inability to undertake any physical activity greater than 3 METs for at least the 5 years before clinical onset or clinical worsening

Diagnosis: Cholelithiasis

Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 30 July 2025, and is supported by an emergency department record and ultrasound abdomen report by the emergency physician and radiologist, dated 21 July 2009.

I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:

Statement of Principles concerning Gallstone Disease (Cholelithiasis) (Balance of Probabilities) (No. 70 of 2025)

which sets out the factors that can connect the condition with service.

I am satisfied that you have met the following factor:

having a spinal cord injury at the time of clinical onset or clinical worsening
having a foreign body in the biliary tract, or a mechanical obstruction of the biliary tract, before clinical onset or clinical worsening
having an ileal resection or ileal bypass within the 25 years before clinical onset or clinical worsening
having a gastric or oesophageal resection, or another operation that includes a vagotomy, within the 5 years before clinical onset or clinical worsening
having one of the following parasitic diseases of the biliary tract at the time of clinical onset or clinical worsening: (a) ascariasis; (b) clonorchiasis; (c) fascioliasis; (d) opisthorchiasis
having Helicobacter pylori infection of the biliary tract at the time of clinical onset or clinical worsening
having cholangiohepatitis or recurrent pyogenic cholangitis at the time of clinical onset or clinical worsening
having an acquired haemolytic disease, characterised by red cell defects and breakdown with bilirubin overproduction, within the 1 year before clinical onset or clinical worsening
having worsening of an inherited haemolytic disease, characterised by red cell defects and breakdown with bilirubin overproduction, within the 1 year before clinical onset or clinical worsening
having a somatostatinoma at the time of clinical onset or clinical worsening
being pregnant within the 3 months before clinical onset or clinical worsening
for males, being obese for at least the 5 years before clinical onset or clinical worsening
for females, being overweight or obese for at least the 5 years before clinical onset or clinical worsening
having rapid and extreme weight loss, involving a reduction of body mass by at least 15 percent: (a) within a continuous 6 month period; or (b) at an average rate of at least 1.5 kilograms per week, and within the 1 year before clinical onset or clinical worsening
having a very low-calorie diet, with an energy intake of less than 800 kilocalories per day, for the 1 year before clinical onset or clinical worsening
having type 2 diabetes mellitus at the time of clinical onset or clinical worsening
having cirrhosis of the liver at the time of clinical onset or clinical worsening
having Crohn disease at the time of clinical onset or clinical worsening
taking any of the following medications for a continuous period of at least 6 months before clinical onset or clinical worsening, and where treatment has ceased, clinical onset or clinical worsening occurred within 3 months of cessation: (a) atazanavir; (b) cyclosporine A; (c) fibrates; (d) somatostatin analogues; (e) tamoxifen
having oestrogen therapy for a continuous period of at least 6 months before clinical onset or clinical worsening, and where oestrogen therapy has ceased, clinical onset or clinical worsening occurred within 3 months of cessation
having total parenteral nutrition for a continuous period of at least 3 weeks before clinical onset or clinical worsening, and where total parenteral nutrition has ceased, clinical onset or clinical worsening occurred within 30 days of cessation
inability to undertake any physical activity greater than 3 METs for at least the 5 years before clinical onset or clinical worsening

I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with episodes of severe, constant right upper quadrant and epigastric pain radiating to the back, lasting two to six hours, usually after meals, with nausea and vomiting on 21 July 2009.

The diagnosis was made on ultrasound on 21 July 2009, which showed multiple mobile, shadowing calculi in the gallbladder up to 9 millimetres with sludge, in a patient presenting with typical biliary colic. The stones exceed 2 millimetres and lie in the gallbladder, meeting the Statement of Principles definition of gallstone disease. The normal gallbladder on ultrasound of 3 September 2008 confirms that the stones formed after that date.

This has then led to further investigations and the diagnosis of your condition of Cholelithiasis. I have accepted your condition of Cholelithiasis.

Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that this condition is related to your peacetime service.

I have therefore accepted that this condition is related to your service with effect from 20 July 2009.

Cholelithiasis (Worsening)

Evidence

The evidence that I have considered in making this decision includes:

Formal Claim with supporting statements;
A Statement of your Service from the Department of Defence;
Copies of your Service Medical Records.
A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 30 July 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 30 July 2025;
A field hospital incident record by the rwanda, and hepatitis serology September 1995, Pathologist, dated 14 May 1995;
An operation report and histology by the colorectal surgeon and pathologist, dated 22 March 2001;
An outpatient health record by the medical officer, Garrison health centre, dated 12 June 2007;
An ultrasound abdomen report and hepatology consultation by the radiologist and hepatologist, dated 3 September 2008;
An obstetric and haematology admission record by the obstetrician and haematologist, dated 14 January 2009;
A gastroenterology admission and parenteral nutrition record by the gastroenterologist, dated 8 June 2009;
An emergency department record and ultrasound abdomen report by the emergency physician and radiologist, dated 21 July 2009;
An aeromedical evacuation and spinal injury unit records by the spinal surgeon, dated 14 September 2011;
An operation report by the general surgeon, dated 26 October 2011;
A transient elastography and liver biopsy report by the hepatologist and pathologist, dated 18 May 2015;
An ERCP report (bile culture and haematology record) by the gastroenterologist and haematologist, dated 12 March 2016;
A hospital admission record by the MRCP and CT abdomen reports, General physician and Radiologist, dated 20 October 2016;
An ERCP report and bile PCR by the gastroenterologist and microbiologist, dated 24 October 2016;
An endoscopic ultrasound biopsy report by the gastroenterologist and pathologist, dated 27 October 2016;
An operation report by the hepatobiliary surgeon, dated 15 March 2017.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

15 January 1990 and 19 December 2013

Cholelithiasis (Worsening)

You have stated that the worsening of your condition was caused by:

having a spinal cord injury at the time of clinical onset or clinical worsening
having a foreign body in the biliary tract, or a mechanical obstruction of the biliary tract, before clinical onset or clinical worsening
having an ileal resection or ileal bypass within the 25 years before clinical onset or clinical worsening
having a gastric or oesophageal resection, or another operation that includes a vagotomy, within the 5 years before clinical onset or clinical worsening
having one of the following parasitic diseases of the biliary tract at the time of clinical onset or clinical worsening: (a) ascariasis; (b) clonorchiasis; (c) dicrocoeliasis; (d) fascioliasis; (e) opisthorchiasis; (f) trypanosomiasis
having bacterial infection of the biliary tract at the time of clinical onset or clinical worsening
having Helicobacter pylori infection of the biliary tract at the time of clinical onset or clinical worsening
having cholangiohepatitis or recurrent pyogenic cholangitis at the time of clinical onset or clinical worsening
having an acquired haemolytic disease, characterised by red cell defects and breakdown with bilirubin overproduction, within the 1 year before clinical onset or clinical worsening
having worsening of an inherited haemolytic disease, characterised by red cell defects and breakdown with bilirubin overproduction, within the 1 year before clinical onset or clinical worsening
having a somatostatinoma at the time of clinical onset or clinical worsening
being pregnant within the 6 months before clinical onset or clinical worsening
for males, being obese for at least the 2 years before clinical onset or clinical worsening
for females, being overweight or obese for at least the 2 years before clinical onset or clinical worsening
having rapid and extreme weight loss, involving a reduction of body mass by at least 15 percent: (a) within a continuous 6 month period; or (b) at an average rate of at least 1.5 kilograms per week, and within the 2 years before clinical onset or clinical worsening
having a very low-calorie diet, with an energy intake of less than 800 kilocalories per day, for the 6 months before clinical onset or clinical worsening
having type 2 diabetes mellitus at the time of clinical onset or clinical worsening
having cirrhosis of the liver at the time of clinical onset or clinical worsening
having metabolic dysfunction-associated steatotic liver disease at the time of clinical onset or clinical worsening
having hepatitis C virus infection at the time of clinical onset or clinical worsening
having Crohn disease or ulcerative colitis at the time of clinical onset or clinical worsening
taking any of the following medications for a continuous period of at least 3 months before clinical onset or clinical worsening, and where treatment has ceased, clinical onset or clinical worsening occurred within 3 months of cessation: (a) atazanavir; (b) cyclosporine A; (c) fibrates; (d) somatostatin analogues; (e) tamoxifen
having oestrogen therapy for a continuous period of at least 3 months before clinical onset or clinical worsening, and where oestrogen therapy has ceased, clinical onset or clinical worsening occurred within 6 months of cessation
having total parenteral nutrition for a continuous period of at least 3 weeks before clinical onset or clinical worsening, and where total parenteral nutrition has ceased, clinical onset or clinical worsening occurred within 30 days of cessation
inability to undertake any physical activity greater than 3 METs for at least the 5 years before clinical onset or clinical worsening
inability to obtain appropriate clinical management for gallstone disease (cholelithiasis) before clinical worsening

Diagnosis: Cholelithiasis (Worsening)

I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:

Statement of Principles concerning Gallstone Disease (Cholelithiasis) (Reasonable Hypothesis) (No. 69 of 2025)

which sets out the factors that can connect the condition with service.

I am satisfied that you have met the following factor:

having a spinal cord injury at the time of clinical onset or clinical worsening
having a foreign body in the biliary tract, or a mechanical obstruction of the biliary tract, before clinical onset or clinical worsening
having an ileal resection or ileal bypass within the 25 years before clinical onset or clinical worsening
having a gastric or oesophageal resection, or another operation that includes a vagotomy, within the 5 years before clinical onset or clinical worsening
having one of the following parasitic diseases of the biliary tract at the time of clinical onset or clinical worsening: (a) ascariasis; (b) clonorchiasis; (c) dicrocoeliasis; (d) fascioliasis; (e) opisthorchiasis; (f) trypanosomiasis
having bacterial infection of the biliary tract at the time of clinical onset or clinical worsening
having Helicobacter pylori infection of the biliary tract at the time of clinical onset or clinical worsening
having cholangiohepatitis or recurrent pyogenic cholangitis at the time of clinical onset or clinical worsening
having an acquired haemolytic disease, characterised by red cell defects and breakdown with bilirubin overproduction, within the 1 year before clinical onset or clinical worsening
having worsening of an inherited haemolytic disease, characterised by red cell defects and breakdown with bilirubin overproduction, within the 1 year before clinical onset or clinical worsening
having a somatostatinoma at the time of clinical onset or clinical worsening
being pregnant within the 6 months before clinical onset or clinical worsening
for males, being obese for at least the 2 years before clinical onset or clinical worsening
for females, being overweight or obese for at least the 2 years before clinical onset or clinical worsening
having rapid and extreme weight loss, involving a reduction of body mass by at least 15 percent: (a) within a continuous 6 month period; or (b) at an average rate of at least 1.5 kilograms per week, and within the 2 years before clinical onset or clinical worsening
having a very low-calorie diet, with an energy intake of less than 800 kilocalories per day, for the 6 months before clinical onset or clinical worsening
having type 2 diabetes mellitus at the time of clinical onset or clinical worsening
having cirrhosis of the liver at the time of clinical onset or clinical worsening
having metabolic dysfunction-associated steatotic liver disease at the time of clinical onset or clinical worsening
having hepatitis C virus infection at the time of clinical onset or clinical worsening
having Crohn disease or ulcerative colitis at the time of clinical onset or clinical worsening
taking any of the following medications for a continuous period of at least 3 months before clinical onset or clinical worsening, and where treatment has ceased, clinical onset or clinical worsening occurred within 3 months of cessation: (a) atazanavir; (b) cyclosporine A; (c) fibrates; (d) somatostatin analogues; (e) tamoxifen
having oestrogen therapy for a continuous period of at least 3 months before clinical onset or clinical worsening, and where oestrogen therapy has ceased, clinical onset or clinical worsening occurred within 6 months of cessation
having total parenteral nutrition for a continuous period of at least 3 weeks before clinical onset or clinical worsening, and where total parenteral nutrition has ceased, clinical onset or clinical worsening occurred within 30 days of cessation
inability to undertake any physical activity greater than 3 METs for at least the 5 years before clinical onset or clinical worsening
inability to obtain appropriate clinical management for gallstone disease (cholelithiasis) before clinical worsening

After the condition arose, it was worsened during your service. On 14 September 2011, during warlike service in Afghanistan, your protected vehicle rolled over on a road move and you sustained a T11 burst fracture with an incomplete spinal cord injury, leaving your paraplegic and a full-time wheelchair user. At ERCP on 12 March 2016 a plastic biliary stent was placed across a hilar stricture caused by recurrent pyogenic cholangitis arising from opisthorchiasis acquired on peacekeeping service in Cambodia. On 22 March 2001 you had an ileocaecal resection, removing 25 centimetres of terminal ileum, for Crohn disease that followed bacterial gastroenteritis on warlike service in East Timor in December 1999. On 26 October 2011 you had an emergency truncal vagotomy and antrectomy for a perforated stress ulcer of the duodenum that developed after your spinal cord injury on warlike service in Afghanistan. During peacekeeping service in Cambodia from November 1992 to June 1993 you ate raw and fermented freshwater fish in villages while working with local communities, and a marked eosinophilia on your return screening was not followed up. Bile cultures at ERCP on 12 March 2016 and 24 October 2016 grew Escherichia coli and Klebsiella pneumoniae, and on 20 October 2016 you were admitted with acute ascending cholangitis, fever, rigors and jaundice. Bile aspirated at ERCP on 24 October 2016 was positive for Helicobacter pylori DNA on PCR, and the gallbladder mucosa at cholecystectomy in 2017 was positive on immunostaining. A hepatobiliary surgeon diagnosed recurrent pyogenic cholangitis in March 2016 after three episodes of cholangitis since 2015, with intrahepatic pigment stones and strictures of the left ductal system on cholangiography. On 18 March 2016, during ceftriaxone treatment for cholangitis, you developed drug-induced immune haemolytic anaemia: haemoglobin fell from 118 to 68 grams per litre, the direct antiglobulin test was positive, bilirubin rose to 96 micromoles per litre and haptoglobin was undetectable. You have hereditary spherocytosis, mild and compensated before 2009. CT on 21 October 2016 showed a 24 millimetre mass in the head of the pancreas, and endoscopic ultrasound biopsy on 27 October 2016 confirmed a well-differentiated neuroendocrine tumour staining for somatostatin, with a fasting plasma somatostatin many times the upper limit of normal. You were pregnant until 10 May 2009, when you were delivered by caesarean section while serving full time as a nursing officer. Your BMI was 31.4 on 15 June 2004 and was recorded at 30 or more at every health examination to onset, 33.2 before pregnancy, so you were obese throughout the 2 years before onset, from 20 July 2007 to 20 July 2009. You were obese, with a BMI of 30 or more, at every recorded health examination from 15 June 2004 to onset, well above the overweight threshold, so you were overweight or obese throughout the 2 years before onset, from 20 July 2007 to 20 July 2009. Under a supervised very low-calorie diet your weight fell from 111 kilograms on 20 October 2015 to 86 kilograms on 20 April 2016, a loss of 22.5 per cent of body mass within a continuous 6 month period, recorded by the bariatric dietitian. From 12 October 2015 you followed a supervised meal-replacement diet of 600 to 750 kilocalories per day, continued to the worsening, so it covered the whole 6 months before the worsening, from 20 April 2016 to 20 October 2016. Type 2 diabetes mellitus was diagnosed on 12 June 2007 with an HbA1c of 7.6 per cent and fasting glucose of 9.1 millimoles per litre, and treated with metformin. Transient elastography on 18 May 2015 showed liver stiffness of 19.8 kilopascals and liver biopsy confirmed cirrhosis, caused by chronic hepatitis C acquired on peacekeeping service in Rwanda together with steatotic liver disease. Ultrasound on 3 September 2008 showed diffuse hepatic steatosis with normal gallbladder and ducts, and a hepatologist diagnosed metabolic dysfunction-associated steatotic liver disease in the setting of obesity and type 2 diabetes. On 14 May 1995, during peacekeeping service in Rwanda, you sustained a needle-stick injury while cannulating a casualty in a field hospital. Crohn disease of the terminal ileum was diagnosed on 18 July 2000 after bacterial gastroenteritis on warlike service in East Timor in December 1999. You took fenofibrate 145 milligrams daily from 10 February 2014 for severe hypertriglyceridaemia (triglycerides 9.8 millimoles per litre) related to your diabetes, continuously to and beyond the worsening on 20 October 2016, a period of more than 2 years. After a total hysterectomy and bilateral salpingo-oophorectomy on 5 August 2013 for a large benign ovarian mass, you were prescribed transdermal oestradiol 50 micrograms daily from 12 August 2013, continued without interruption to the worsening on 20 October 2016, more than 3 years. After the caesarean delivery your Crohn disease flared with subacute small bowel obstruction, and you received total parenteral nutrition through a central line from 8 June 2009 to 6 July 2009, a continuous period of 28 days. Since your spinal cord injury on warlike service in Afghanistan on 14 September 2011 you have been paraplegic and unable to stand or walk, and your rehabilitation physician recorded that you cannot undertake any activity above about 2 METs. Cholecystectomy was recommended after onset in July 2009 but was deferred because of you Crohn flare and then your deployment to Afghanistan, where you had three attacks of biliary colic between June and August 2011 that could only be managed with analgesia.

This has then led to further investigations and the diagnosis of your condition of Cholelithiasis (Worsening). I have accepted your condition of Cholelithiasis (Worsening).

Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that the worsening of this condition is related to your wartime service.

I have therefore accepted that the worsening of this condition is related to your service with effect from 14 September 2011.

Cholelithiasis — example determination letter

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Reference Determination Content

Cholelithiasis

Evidence

Your service

Cholelithiasis

Cholelithiasis (Worsening)

Evidence

Your service

Cholelithiasis (Worsening)