Reference Determination Content
Suggested draft · fictitious patient
Gastroesophageal Reflux Disease - Medication - Induced
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 8 April 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 8 April 2025;
- A rheumatology consultation by the rheumatologist, dated 10 August 2012;
- A deployed health record by the medical officer, Middle East Area of Operations, dated 18 October 2013;
- A post-deployment health assessment by the medical officer, Garrison health centre, dated 29 January 2014;
- A CT abdomen and operation report by the radiologist and general surgeon, dated 2 October 2014;
- An outpatient health record by the medical officer, Garrison health centre, dated 16 March 2015;
- A gastroscopy and histopathology report by the gastroenterologist, dated 15 February 2016;
- A psychiatric assessment by the consultant psychiatrist, dated 10 June 2016;
- A gastroscopy (dilatation and barium swallow reports) by the gastroenterologist and radiologist, dated 14 April 2017;
- A gastroscopy and histopathology report by the gastroenterologist, dated 20 August 2017;
- A specialist follow-up by the gastroenterologist, dated 24 January 2018.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
18 January 2005 and 14 November 2019
Gastroesophageal Reflux Disease - Medication - Induced
You have stated that your condition was caused by:
- having a hiatus hernia at the time of the clinical onset of gastro-oesophageal reflux disease
- being overweight or obese at the time of the clinical onset of gastro-oesophageal reflux disease
- having smoked tobacco products: (a) in an amount of at least 3 pack-years before the clinical onset of gastro-oesophageal reflux disease; and (b) commencing at least 5 years before the clinical onset of gastro-oesophageal reflux disease; and if smoking has ceased before the clinical onset of gastro-oesophageal reflux disease, then that onset occurred within 1 year of cessation
- consuming an average of at least 500 grams of alcohol per week for at least the 1 year before the clinical onset of gastro-oesophageal reflux disease
- undergoing surgery to the region of the oesophageal hiatus or surgery involving the fundus or body of the stomach, within the 6 months before the clinical onset of gastro-oesophageal reflux disease
- taking a drug from the Specified List 1 of drugs at the time of the clinical onset of gastro-oesophageal reflux disease
- having a disease from the specified list of diseases at the time of the clinical onset of gastro-oesophageal reflux disease
- being pregnant at the time of the clinical onset of gastro-oesophageal reflux disease
Diagnosis: Medication - Induced
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 8 April 2025, and is supported by a gastroscopy and histopathology report by the gastroenterologist, dated 15 February 2016.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Gastro-Oesophageal Reflux Disease (Balance of Probabilities) (No. 62 of 2021)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- having a hiatus hernia at the time of the clinical onset of gastro-oesophageal reflux disease
- being overweight or obese at the time of the clinical onset of gastro-oesophageal reflux disease
- having smoked tobacco products: (a) in an amount of at least 3 pack-years before the clinical onset of gastro-oesophageal reflux disease; and (b) commencing at least 5 years before the clinical onset of gastro-oesophageal reflux disease; and if smoking has ceased before the clinical onset of gastro-oesophageal reflux disease, then that onset occurred within 1 year of cessation
- consuming an average of at least 500 grams of alcohol per week for at least the 1 year before the clinical onset of gastro-oesophageal reflux disease
- undergoing surgery to the region of the oesophageal hiatus or surgery involving the fundus or body of the stomach, within the 6 months before the clinical onset of gastro-oesophageal reflux disease
- taking a drug from the Specified List 1 of drugs at the time of the clinical onset of gastro-oesophageal reflux disease
- having a disease from the specified list of diseases at the time of the clinical onset of gastro-oesophageal reflux disease
- being pregnant at the time of the clinical onset of gastro-oesophageal reflux disease
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 daily heartburn, acid regurgitation, a nocturnal cough and hoarseness, worse lying down and after meals on 16 March 2015.
The diagnosis was confirmed by gastroscopy on 15 February 2016, which showed Los Angeles grade A reflux oesophagitis and a 3 cm sliding hiatus hernia, with biopsies showing reflux oesophagitis and excluding Barrett oesophagus. This meets the Statement of Principles definition: retrograde flow of gastric contents causing both symptoms warranting regular medical treatment and histological evidence of oesophageal inflammation.
This has then led to further investigations and the diagnosis of your condition of Medication - Induced. I have accepted your condition of Medication - Induced.
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 12 March 2015.
Gastroesophageal Reflux Disease - Medication - Induced (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 8 April 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 8 April 2025;
- A rheumatology consultation by the rheumatologist, dated 10 August 2012;
- A deployed health record by the medical officer, Middle East Area of Operations, dated 18 October 2013;
- A post-deployment health assessment by the medical officer, Garrison health centre, dated 29 January 2014;
- A CT abdomen and operation report by the radiologist and general surgeon, dated 2 October 2014;
- An outpatient health record by the medical officer, Garrison health centre, dated 16 March 2015;
- A gastroscopy and histopathology report by the gastroenterologist, dated 15 February 2016;
- A psychiatric assessment by the consultant psychiatrist, dated 10 June 2016;
- A gastroscopy (dilatation and barium swallow reports) by the gastroenterologist and radiologist, dated 14 April 2017;
- A gastroscopy and histopathology report by the gastroenterologist, dated 20 August 2017;
- A specialist follow-up by the gastroenterologist, dated 24 January 2018.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
18 January 2005 and 14 November 2019
Gastroesophageal Reflux Disease - Medication - Induced (Worsening)
You have stated that the worsening of your condition was caused by:
- having a hiatus hernia at the time of the clinical worsening of gastro-oesophageal reflux disease
- being overweight or obese at the time of the clinical worsening of gastro-oesophageal reflux disease
- having smoked tobacco products: (a) in an amount of at least 3 pack-years before the clinical worsening of gastro-oesophageal reflux disease; and (b) commencing at least 5 years before the clinical worsening of gastro-oesophageal reflux disease; and if smoking has ceased before the clinical worsening of gastro-oesophageal reflux disease, then that worsening occurred within 1 year of cessation
- consuming an average of at least 500 grams of alcohol per week for at least the 1 year before the clinical worsening of gastro-oesophageal reflux disease
- undergoing surgery to the region of the oesophageal hiatus or surgery involving the fundus or body of the stomach, within the 6 months before the clinical worsening of gastro-oesophageal reflux disease
- taking a drug from the Specified List 1 of drugs at the time of the clinical worsening of gastro-oesophageal reflux disease
- having a disease from the specified list of diseases at the time of the clinical worsening of gastro-oesophageal reflux disease
- being pregnant at the time of the clinical worsening of gastro-oesophageal reflux disease
- having a disorder of mental health from the specified list of disorders of mental health at the time of the clinical worsening of gastro-oesophageal reflux disease
- taking orally a drug from the Specified List 2 of drugs at the time of the clinical worsening of gastro-oesophageal reflux disease
- taking orally a drug which is associated in the individual with the clinical worsening of gastro-oesophageal reflux disease during drug therapy and either: (a) the improvement of gastro-oesophageal reflux disease within 3 months of discontinuing or tapering drug therapy; or (b) the clinical worsening of gastro-oesophageal reflux disease on rechallenge with the same drug; and where the drug was being taken at the time of the clinical worsening of gastro-oesophageal reflux disease
- inability to obtain appropriate clinical management for gastro-oesophageal reflux disease
Diagnosis: Medication - Induced (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 8 April 2025, and is supported by a gastroscopy and histopathology report by the gastroenterologist, dated 15 February 2016.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Gastro-Oesophageal Reflux Disease (Balance of Probabilities) (No. 62 of 2021)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- having a hiatus hernia at the time of the clinical worsening of gastro-oesophageal reflux disease
- being overweight or obese at the time of the clinical worsening of gastro-oesophageal reflux disease
- having smoked tobacco products: (a) in an amount of at least 3 pack-years before the clinical worsening of gastro-oesophageal reflux disease; and (b) commencing at least 5 years before the clinical worsening of gastro-oesophageal reflux disease; and if smoking has ceased before the clinical worsening of gastro-oesophageal reflux disease, then that worsening occurred within 1 year of cessation
- consuming an average of at least 500 grams of alcohol per week for at least the 1 year before the clinical worsening of gastro-oesophageal reflux disease
- undergoing surgery to the region of the oesophageal hiatus or surgery involving the fundus or body of the stomach, within the 6 months before the clinical worsening of gastro-oesophageal reflux disease
- taking a drug from the Specified List 1 of drugs at the time of the clinical worsening of gastro-oesophageal reflux disease
- having a disease from the specified list of diseases at the time of the clinical worsening of gastro-oesophageal reflux disease
- being pregnant at the time of the clinical worsening of gastro-oesophageal reflux disease
- having a disorder of mental health from the specified list of disorders of mental health at the time of the clinical worsening of gastro-oesophageal reflux disease
- taking orally a drug from the Specified List 2 of drugs at the time of the clinical worsening of gastro-oesophageal reflux disease
- taking orally a drug which is associated in the individual with the clinical worsening of gastro-oesophageal reflux disease during drug therapy and either: (a) the improvement of gastro-oesophageal reflux disease within 3 months of discontinuing or tapering drug therapy; or (b) the clinical worsening of gastro-oesophageal reflux disease on rechallenge with the same drug; and where the drug was being taken at the time of the clinical worsening of gastro-oesophageal reflux disease
- inability to obtain appropriate clinical management for gastro-oesophageal reflux disease
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 daily heartburn, acid regurgitation, a nocturnal cough and hoarseness, worse lying down and after meals on 16 March 2015.
The diagnosis was confirmed by gastroscopy on 15 February 2016, which showed Los Angeles grade A reflux oesophagitis and a 3 cm sliding hiatus hernia, with biopsies showing reflux oesophagitis and excluding Barrett oesophagus. This meets the Statement of Principles definition: retrograde flow of gastric contents causing both symptoms warranting regular medical treatment and histological evidence of oesophageal inflammation.
After the condition arose, it was worsened during your service. Gastroscopy on 20 August 2017, the date of the worsening, showed a 4 cm sliding hiatus hernia, enlarged from 3 cm in 2016. Your BMI was 29.4 on 20 August 2017, in the overweight range, with a waist circumference of 96 centimetres, above the 80 centimetre threshold for women. By 20 August 2017 you had smoked for 13 years, commencing in 2004, more than 5 years before the worsening, and had accumulated about 10 pack-years. Your drinking relapsed to about 60 standard drinks a week after the birth of your son, as recorded by your psychiatrist on 10 June 2016. On 14 April 2017 a gastroenterologist dilated a peptic stricture at the gastro-oesophageal junction to 15 mm with a balloon. At the worsening on 20 August 2017 you were still taking amitriptyline 50 mg at night for service-related neck pain, a tricyclic antidepressant on Specified List 1. Sjögren syndrome remained active at the worsening, with persisting dry mouth recorded by your rheumatologist in July 2017. You were 12 weeks pregnant at the worsening on 20 August 2017, your second pregnancy having been confirmed on 10 July 2017. A psychiatrist diagnosed anxiety disorder on 10 June 2016, related to the rocket attack on deployment and the demands of service, and it was under active treatment with sertraline at the worsening. At the worsening on 20 August 2017 you were taking orally doxycycline 100 mg daily (an antibiotic, a tetracycline), naproxen (a nonsteroidal anti-inflammatory agent) and sertraline 100 mg daily (a selective serotonin re-uptake inhibitor), all on Specified List 2 and all prescribed during service. Oral doxycycline, started in February 2017, was associated in this veteran with the worsening to Los Angeles grade C oesophagitis. Throughout your first pregnancy, from March to October 2015, proton pump inhibitors were withheld and gastroscopy deferred, and the Specified List 1 drugs that were driving the reflux were not reviewed or substituted.
This has then led to further investigations and the diagnosis of your condition of Medication - Induced (Worsening). I have accepted your condition of Medication - Induced (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 peacetime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 20 August 2017.
