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5.3.8 Digestive System Disorder - Table 8
Table 8.1. and Irritable Bowel Syndrome Claims
The following aims to provide policy guidance on how Irritable Bowel Syndrome (IBS) can be assessed under the Permanent Impairment Guide (PI Guide) as prescribed by the Safety, Rehabilitation and Compensation Act 1988 (SRCA).
Irritable Bowel Syndrome is characterised by chronic, usually intermittent, abdominal pain and altered bowel habit. It is not associated with malnutrition, weight loss, rectal bleeding, or pain that interferes with sleep. It most usually requires diagnosis by a Gastroenterologist after exclusion of other pathologies. Most patients experience mild symptoms though, in rare severe cases, it can cause significant disability and interference with life.
While objective evidence of IBS can exist, it is possible, and indeed common, for the condition to be diagnosed without any objective evidence of disease. However, the PI Guide requires objective signs or symptoms of disease be present before any whole person impairment (WPI) rating can be given.
While impairment ratings are possible for clients with an IBS diagnosis, the most common impairment rating for most IBS cases will still be 0 points, as the symptomology of prototypical IBS cases will not be enough to rate on the PI Guide tables– only relatively severe cases will attract a rating under table 8.1.
Table 8.1 ‘Disorders of the oesophagus, stomach, duodenum, small intestine, pancreas, colon, rectum and anus’
Objective signs refers to evidence of the condition which is perceptible to the examiner. Subjective sensations of the individual is not acceptable. This concept is reinforced in several cases before the Administrative Appeals Tribunal (AAT).
In the case of Re Florit and Comcare (2004) 81 ALD 774, the AAT considered the meaning of ‘objective signs’:
The need for ‘objective signs’ means, in our view, the need for objective signs of a stomach disorder to be present on an ongoing basis such as, for example, by way of endoscopy. In a medical context the adjective ‘objective’ is used to refer to a sign or symptom that can be perceived by others in addition to the patient. A symptom only the patient can perceive is ‘subjective’.
It is possible for there to be objective signs of IBS.
In order of likelihood of being mentioned, some objective signs are:
Variable abdominal distention
This may be noted on clinical examination (on at least 2 occasions) and represent bloating and/or constipation. Abdominal distention on one occasion, or unchanging, is not a useful finding.
Variable abdominal tenderness
This is a weak sign, but may provide the Specialist with additional diagnostic evidence if the condition is being considered. There would be scope for the Delegate to use this as evidence, if it was felt that a rating was justified.
A stool diary
The recording of stool frequency and consistency is performed in a standardised manner in healthcare settings.
Variation, in the setting of a consistent diet, would be strong supporting evidence of IBS.
Any abnormal frequency, even if regular, is objective only if kept by a third party (e.g. by a nurse).
Recording of pain (part of standard “observations” in the hospital setting) and comparison to the timing of defecation might demonstrate a relationship and would thus be objective.
Patients are often asked to keep a stool diary for a period of time to assess response to treatment. This could be considered objective, at the discretion of the Specialist and/or the Delegate.
Intestinal / colonic transit time
This could be represented by either increased or decreased transit time. This is unlikely to be specifically tested in IBS, but may be noted as part of the work-up to exclude other conditions. This may be seen on a CT scan with oral contrast, or a “pill-cam” test.
This list is not exhaustive; other tests or signs may be appropriate as the medical science consensus around IBS improves or changes. Delegates should consult with Policy if unsure whether a claimed sign or symptom is objective.
Some of the tests for objective signs can be invasive and may not be possible in all cases. Again, the suggestions above are not prescriptive - in situations where an assessing medical practitioner is satisfied that a patient is able to show objective signs, then it is open for the delegate to accept the evidence and assessment provided.
Table 8.1 also requires the finding of weight loss at certain impairment levels. Generally, weight loss is not a recognised component of IBS. Therefore, this limits the possible ratings under PIG for IBS to the following:
All other ratings are not possible, as they require that weight loss must be present.
The advice provided in this article is general in nature and does not take into account individual circumstances. Delegates must always consider the medical information available to them and make assessments and determinations accordingly.