Statement of Principles

concerning

DUODENAL ULCER AND DUODENAL EROSION
(Balance of Probabilities)

(No. 50 of 2024)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans' Entitlements Act 1986.

Dated 21 June 2024.

Contents

1 Name

2 Commencement

3 Authority

4 Repeal

5 Application

6 Definitions

7 Kind of injury, disease or death to which this Statement of Principles relates

8 Basis for determining the factors

9 Factors that must exist

10 Relationship to service

11 Factors referring to an injury or disease covered by another Statement of Principles

Schedule 1 - Dictionary

1 Definitions

1               Name

This is the Statement of Principles concerning duodenal ulcer and duodenal erosion (Balance of Probabilities) (No. 50 of 2024).

2               Commencement

              This instrument commences on 23 July 2024.

3               Authority

This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986.

4               Repeal

The Statement of Principles concerning gastric ulcer and duodenal ulcer No. 62 of 2015 (Federal Register of Legislation No. F2015L00658) made under subsections 196B(3) and (8) of the VEA is repealed.

5               Application

This instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies.

6               Definitions

The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.

7               Kind of injury, disease or death to which this Statement of Principles relates

(1)          This Statement of Principles is about duodenal ulcer and duodenal erosion and death from duodenal ulcer and duodenal erosion.

Meaning of duodenal ulcer and duodenal erosion

(2)          For the purposes of this Statement of Principles, duodenal ulcer and duodenal erosion:

(a)          means a non-malignant disruption in the mucosal surface of the duodenum; and

(b)          includes ulcers or erosions due to duodenal foreign bodies; and

(c)          excludes:

(i)            acute superficial mucosal erosions of the duodenum; and

(ii)         duodenal perforations from external trauma such as stabbing, explosive blast injury or gunshot injury;

Note: A duodenal erosion is a disruption in the mucosal surface of the duodenum above the lamina propria, and a duodenal ulcer is a disruption in the mucosal surface of duodenum that extends past the lamina propria and through the muscularis mucosa into the submucosa.

(3)          While duodenal ulcer and duodenal erosion attracts ICD‑10‑AM code K26, in applying this Statement of Principles the meaning of duodenal ulcer and duodenal erosion is that given in subsection (2).

(4)          For subsection (3), a reference to an ICD-10-AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4.

Death from duodenal ulcer and duodenal erosion

(5)          For the purposes of this Statement of Principles, duodenal ulcer and duodenal erosion, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's duodenal ulcer and duodenal erosion.

Note: terminal event is defined in the Schedule 1 – Dictionary.

8               Basis for determining the factors

On the sound medical‑scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that duodenal ulcer and duodenal erosion and death from duodenal ulcer and duodenal erosion can be related to relevant service rendered by veterans or members of the Forces under the VEA, or members under the MRCA.

Note: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary.

9               Factors that must exist

At least one of the following factors must exist before it can be said that, on the balance of probabilities, duodenal ulcer and duodenal erosion or death from duodenal ulcer and duodenal erosion is connected with the circumstances of a person's relevant service:

(1)          having Helicobacter pylori infection of the duodenum at the time of clinical onset or clinical worsening;

(2)           having an infection of the duodenal mucosa by one of the following organisms:

(a)          cytomegalovirus;

(b)          herpes simplex virus;

(c)          fungi (such as Candida species or Histoplasma capsulatum);

(d)          Helicobacter heilmannii;

(e)          Mycobacterium tuberculosis;

(f)           Strongyloides stercoralis (causing strongyloidiasis);

at the time of clinical onset or clinical worsening;

(3)          having a critical illness or injury within the 14 days before clinical onset or clinical worsening;

Note: critical illness or injury is defined in the Schedule 1 - Dictionary.

(4)          undergoing a course of radiotherapy for cancer, where the stomach or duodenum was in the field of radiation, within the 6 months before  clinical onset or clinical worsening;

(5)          undergoing 90Yttrium microsphere therapy for primary and metastatic liver tumours, within the 6 months before clinical onset or clinical worsening;

(6)          having contact with a nasogastric tube or other foreign objects or extraneous material at the site of the ulcer or erosion at the time of clinical onset or clinical worsening;

(7)          having Roux-en-Y gastric bypass within the 5 years before clinical onset or clinical worsening of duodenal ulcer or duodenal erosion, where the ulcer or erosion occurred at the site of the surgical anastomosis;

(8)          having a gastrin-secreting tumour at the time of clinical onset or clinical worsening;

(9)          smoking at least 10 cigarettes per day, or the equivalent thereof in other tobacco products, for at least the 12 months before clinical onset or clinical worsening;

(10)      being treated with a non-topical non-steroidal anti-inflammatory drug, or aspirin, at least every other day during a continuous period of at least 14 days, within the 3 months before clinical onset or clinical worsening;

(11)      having a solid organ or bone marrow transplant before clinical onset or clinical worsening;

(12)      being treated with an antineoplastic agent within the 3 months before clinical onset or clinical worsening;

Note: antineoplastic agent is defined in the Schedule 1 - Dictionary.

(13)      being treated with one of the following drugs or class of drugs at the time of clinical onset or clinical worsening:

(a)          bisphosphonate, including alendronate;

(b)          chemotherapeutic agents delivered by hepatic arterial infusion; or

(c)          potassium chloride tablet (enteric coated or wax formulation);

(14)      being treated with one of the following drugs or class of drugs for at least 2 weeks, within the 3 months before clinical onset;

(a)          clopidogrel;

(b)          glucocorticoid, excluding topical or inhaled;

(c)          deferasirox;

(d)          nicorandil;

(e)          paracetamol of more than 2 grams daily; or

(f)           selective serotonin re-uptake inhibitors;

(15)      taking one of the following drugs or class of drugs for at least 2 weeks, within the 3 months before clinical worsening;

(a)          anticoagulants;

(b)          clopidogrel;

(c)          corticosteroids, excluding topical or inhaled;

(d)          lanthanum;

(e)          levodopa with benserazide or carbidopa;

(f)           methylnaltrexone;

(g)          nicotinic acid;

(h)          paracetamol of more than 2 grams daily;

(i)            pentoxifylline;

(j)            selective serotonin re-uptake inhibitors; 

(k)          spironolactone;

(l)            tocilizumab;

(m)        tofacitinib; or

(n)          upadacitinib;

(16)      having cirrhosis of the liver at the time of clinical onset or clinical worsening;

(17)      having alcohol use disorder or drinking at least 4 standard drinks per day for at least 6 months at the time of bleeding of a duodenal ulcer;

Note 1: The bleeding of a duodenal ulcer is considered to be a clinical worsening.

Note 2: Alcohol consumption is calculated utilising the Australian Standard of 10 grams of alcohol per standard alcoholic drink.

(18)      having Crohn disease (a type of inflammatory bowel disease) at the time of clinical onset or clinical worsening;

(19)      having one of the following medical conditions at the time of clinical onset or clinical worsening;

(a)          amyloidosis;

(b)          eosinophilic gastroenteritis;

(c)          sarcoidosis;

(d)          systemic mastocytosis;

Note: systemic mastocytosis is defined in the Schedule 1 – Dictionary.

(20)      inability to obtain appropriate clinical management for duodenal ulcer and duodenal erosion before clinical worsening.

10           Relationship to service

(1)          The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.

(2)          The clinical worsening aspects of factors set out in section 9 apply only to material contribution to, or aggravation of, duodenal ulcer and duodenal erosion where the person's duodenal ulcer and duodenal erosion was suffered or contracted before or during (but did not arise out of) the person's relevant service.

11           Factors referring to an injury or disease covered by another Statement of Principles

In this Statement of Principles:

(1)          if a factor referred to in section 9 applies in relation to a person; and

(2)          that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(3) of the VEA;

then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.

Schedule 1 - Dictionary  

Note:               See Section 6

1               Definitions

In this instrument:

                               antineoplastic agent means any of the following:

(a)          alkylating agents;

(b)          antimetabolites;

(c)           antineoplastic antibodies; or

(d)          kinase inhibitors.

                               critical illness or injury means:

(a)          any physical injury or illness requiring mechanical ventilation support or admission to an intensive care unit;

(b)          acute renal tubular necrosis;

(c)          adult respiratory distress syndrome;

(d)          2nd degree burns covering a total burn area of 50-70%, or 3rd degree burns covering an area >20% of total body surface;

(e)          disseminated intravascular coagulation;

(f)           multiple organ failure; or

(g)          septicaemia.

                               duodenal ulcer and duodenal erosion—see subsection 7(2).

                             MRCA means the Military Rehabilitation and Compensation Act 2004.

                             relevant service means:

(a)          eligible war service (other than operational service) under the VEA;

(b)          defence service (other than hazardous service and British nuclear test defence service) under the VEA; or

(c)          peacetime service under the MRCA.

Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary.

                               systemic mastocytosis means a mast cell hyperplasia that is generally detected in the bone marrow, skin, gastrointestinal mucosa, liver or spleen.

                             terminal event means the proximate or ultimate cause of death and includes the following:

(a)           pneumonia;

(b)           respiratory failure;

(c)           cardiac arrest;

(d)           circulatory failure; or

(e)           cessation of brain function.

                             VEA means the Veterans' Entitlements Act 1986.