Reference Determination Content
Suggested draft · fictitious patient
Haemorrhoids
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 9 September 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 9 September 2025;
- A trauma admission by the MRI spine and spinal injuries discharge summary, Spinal surgeon, dated 3 September 2009;
- A pre-deployment medical examination by the medical officer, Garrison health centre, dated 22 September 2014;
- A clinic record and stool culture by the contingent medical officer, South Sudan, dated 10 November 2014;
- A contingent diet survey by the contingent medical officer, dated 14 January 2015;
- A united Nations level 1 clinic record by the contingent medical officer, dated 25 February 2015;
- A proctoscopy and pelvic ultrasound reports by the regional hospital surgeon and sonographer, dated 3 March 2015;
- An obstetric telehealth consultation by the obstetrician, dated 12 March 2015;
- A clinic record and blood results by the contingent medical officer, dated 30 April 2015;
- An operation report and histopathology by the colorectal surgeon and pathologist, dated 14 March 2016.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
22 January 2004 and 14 June 2021
Haemorrhoids
You have stated that your condition was caused by:
- being pregnant within the 6 weeks before clinical onset or clinical worsening
- straining at stool due to constipation or diarrhoea, within the 2 weeks before clinical onset or clinical worsening
- having a spinal cord injury at the time of the clinical onset or clinical worsening
- having a pelvic space occupying lesion of sufficient size to impinge on the rectal veins at clinical onset or clinical worsening
- chewing khat at least weekly, for at least the 3 months before clinical onset or clinical worsening
- an inability to consume an average daily intake of 20 grams of fibre in food for at least the 3 months before clinical onset
- having irritable bowel syndrome for at least the 3 months before clinical onset
Diagnosis: Haemorrhoids
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 9 September 2025, and is supported by a proctoscopy and pelvic ultrasound reports by the regional hospital surgeon and sonographer, dated 3 March 2015.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Haemorrhoids (Reasonable Hypothesis) (No. 19 of 2026)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- being pregnant within the 6 weeks before clinical onset or clinical worsening
- straining at stool due to constipation or diarrhoea, within the 2 weeks before clinical onset or clinical worsening
- having a spinal cord injury at the time of the clinical onset or clinical worsening
- having a pelvic space occupying lesion of sufficient size to impinge on the rectal veins at clinical onset or clinical worsening
- chewing khat at least weekly, for at least the 3 months before clinical onset or clinical worsening
- an inability to consume an average daily intake of 20 grams of fibre in food for at least the 3 months before clinical onset
- having irritable bowel syndrome for at least the 3 months before clinical onset
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 painless bright red bleeding with bowel motions, a lump at the anus after defecation that reduced spontaneously, perianal itch and discomfort, and a feeling of incomplete emptying on 25 February 2015.
The diagnosis was made on the history of bright red rectal bleeding and spontaneously reducing prolapse on 25 February 2015 and confirmed on proctoscopy at the regional hospital on 3 March 2015, which showed second-degree internal haemorrhoids at the 3, 7 and 11 o'clock positions. This meets the Statement of Principles definition of haemorrhoids.
This has then led to further investigations and the diagnosis of your condition of Haemorrhoids. I have accepted your condition of Haemorrhoids.
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 wartime service.
I have therefore accepted that this condition is related to your service with effect from 23 February 2015.
Haemorrhoids (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 9 September 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 9 September 2025;
- A trauma admission by the MRI spine and spinal injuries discharge summary, Spinal surgeon, dated 3 September 2009;
- A pre-deployment medical examination by the medical officer, Garrison health centre, dated 22 September 2014;
- A clinic record and stool culture by the contingent medical officer, South Sudan, dated 10 November 2014;
- A contingent diet survey by the contingent medical officer, dated 14 January 2015;
- A united Nations level 1 clinic record by the contingent medical officer, dated 25 February 2015;
- A proctoscopy and pelvic ultrasound reports by the regional hospital surgeon and sonographer, dated 3 March 2015;
- An obstetric telehealth consultation by the obstetrician, dated 12 March 2015;
- A clinic record and blood results by the contingent medical officer, dated 30 April 2015;
- An operation report and histopathology by the colorectal surgeon and pathologist, dated 14 March 2016.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
22 January 2004 and 14 June 2021
Haemorrhoids (Worsening)
You have stated that the worsening of your condition was caused by:
- being pregnant within the 6 weeks before clinical onset or clinical worsening
- straining at stool due to constipation or diarrhoea, within the 2 weeks before clinical onset or clinical worsening
- having a spinal cord injury at the time of the clinical onset or clinical worsening
- having a pelvic space occupying lesion of sufficient size to impinge on the rectal veins at clinical onset or clinical worsening
- chewing khat at least weekly, for at least the 3 months before clinical onset or clinical worsening
- an inability to consume an average daily intake of 20 grams of fibre in food for at least the 4 weeks before clinical worsening
- having irritable bowel syndrome for at least the 4 weeks before clinical worsening
- having receptive anal intercourse within the 48 hours before clinical worsening
- taking anticoagulants, antiplatelet agents, or nonsteroidal anti-inflammatory drugs within the 30 days before hemorrhoidal bleeding
- inability to obtain appropriate clinical management for haemorrhoids before clinical worsening
Diagnosis: Haemorrhoids (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 9 September 2025, and is supported by a proctoscopy and pelvic ultrasound reports by the regional hospital surgeon and sonographer, dated 3 March 2015.
I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:
Statement of Principles concerning Haemorrhoids (Reasonable Hypothesis) (No. 19 of 2026)
which sets out the factors that can connect the condition with service.
I am satisfied that you have met the following factor:
- being pregnant within the 6 weeks before clinical onset or clinical worsening
- straining at stool due to constipation or diarrhoea, within the 2 weeks before clinical onset or clinical worsening
- having a spinal cord injury at the time of the clinical onset or clinical worsening
- having a pelvic space occupying lesion of sufficient size to impinge on the rectal veins at clinical onset or clinical worsening
- chewing khat at least weekly, for at least the 3 months before clinical onset or clinical worsening
- an inability to consume an average daily intake of 20 grams of fibre in food for at least the 4 weeks before clinical worsening
- having irritable bowel syndrome for at least the 4 weeks before clinical worsening
- having receptive anal intercourse within the 48 hours before clinical worsening
- taking anticoagulants, antiplatelet agents, or nonsteroidal anti-inflammatory drugs within the 30 days before hemorrhoidal bleeding
- inability to obtain appropriate clinical management for haemorrhoids before 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 painless bright red bleeding with bowel motions, a lump at the anus after defecation that reduced spontaneously, perianal itch and discomfort, and a feeling of incomplete emptying on 25 February 2015.
The diagnosis was made on the history of bright red rectal bleeding and spontaneously reducing prolapse on 25 February 2015 and confirmed on proctoscopy at the regional hospital on 3 March 2015, which showed second-degree internal haemorrhoids at the 3, 7 and 11 o'clock positions. This meets the Statement of Principles definition of haemorrhoids.
After the condition arose, it was worsened during your service. You conceived during your non-warlike service with a United Nations mission in South Sudan, where your husband was also serving, and the pregnancy was confirmed in theatre on 01 and 3 March 2015. During non-warlike service in South Sudan you strained at stool from 09 February to 22 February 2015, during a constipation-predominant phase of post-infectious irritable bowel syndrome made worse by the low-fibre ration diet and khat. The incomplete T11 spinal cord injury of 3 September 2009 was present, with sensory deficits and neurogenic constipation, throughout your non-warlike service in South Sudan, where its bowel effects were aggravated by the ration diet and limited facilities. Pelvic ultrasound at the regional hospital on 3 March 2015 showed a 9 cm left ovarian mature cystic teratoma lying in the pouch of Douglas behind the uterus, compressing the rectosigmoid junction and the rectal venous plexus. During non-warlike service in South Sudan you chewed khat at least weekly from 1 November 2014 at social gatherings with local staff in the compound. The ration diet continued in South Sudan after onset, with fibre intake of about 12 grams a day recorded on 15 April 2015, throughout the 4 weeks before the worsening, from 02 April to 30 April 2015. The irritable bowel syndrome continued in South Sudan throughout the 4 weeks before the worsening, from 02 April to 30 April 2015, with diarrhoea-predominant episodes recorded on 15 and 27 April 2015. At your examination on 30 April 2015 you disclosed receptive anal intercourse with your husband, a fellow member of the contingent, on the night of 28 April 2015, during their non-warlike service in South Sudan. Aspirin 100 mg nightly was commenced on 12 March 2015 during non-warlike service in South Sudan, on obstetric telehealth advice for pre-eclampsia prophylaxis, and taken daily to the haemorrhoidal bleeding of 30 April 2015, within the 30 days before it. During non-warlike service in South Sudan your haemorrhoids could not be assessed or treated by a surgeon from referral on 5 March 2015 until after the worsening, because no surgical service was available and transfer was delayed by insecurity and lack of flights.
This has then led to further investigations and the diagnosis of your condition of Haemorrhoids (Worsening). I have accepted your condition of Haemorrhoids (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 30 April 2015.
