External
Policy & Procedure

5.3.8.1. - Case Studies

Case 1. A 32-year-old female veteran with symptoms of recurrent abdominal pain and loose stools. She has experienced these symptoms since developing gastroenteritis on deployment to East Timor. Her symptoms are worse during stressful periods, but currently mild. She is currently working full time. Pain is rated at 3/10 at worst, and she has loose stools 2-3 days per week but no incontinence. She takes pain killers only occasionally.

Discussion. This is the typical picture of mild IBS.

Text Box: Likely PIG Impairment Rating - 0% WPI. There are no clear objective signs, no anatomical loss, and no continuous treatment. Likely GARP Impairment Rating – 0% WPI. Likely AMA Impairment Rating – 0% WPI.

Case 2. A 40 year old male veteran diagnosed with IBS as a consequence of PTSD. He describes significant bloating and abdominal pain on most days and suffers mainly from constipation, though with episodes of diarrhoea for a few days once a month. He has been placed on a low FODMAP, high fibre diet by his Gastroenterologist with good effect and takes no regular medication.

Discussion. This is a typical DVA client with IBS. A medically prescribed dietary restriction is required for control.

Text Box: Likely PIG Impairment Rating - 0% WPI. There is no objective evidence described. Potential for 10% rating if objective evidence is presented. Likely GARP Impairment Rating - 5% WPI per table 6.1.8. Likely AMA Impairment Rating – 0-9% WPI per table 6-4.

Case 3. A 25 year old male veteran developed Major Depression and IBS after a motor vehicle rollover during training. His depressive symptoms are in partial remission following extensive psychological therapy. However, he still had 2-3 loose bowel actions each day, each with an urgent need to defecate, which interfered with his work duties. A trial of sertraline was initiated with a reduction in frequency and urgency of defecation.

Discussion. This is a typical DVA client with IBS. Medication specifically prescribed for this condition has provided reasonable control.

Text Box: Likely PIG Impairment Rating - 0% WPI. There is no objective evidence described. Potential for 10% rating if objective evidence is presented. Likely GARP Impairment Rating - 10% WPI per table 6.1.8. Likely AMA Impairment Rating – 0-9% WPI per table 6-4.

In both case 2 and case 3, the level of impairment and the requirement for treatment likely warrant a rating of 10% on the presentation of objective evidence. It can be almost guaranteed that if either veteran was admitted to hospital (e.g. for a colonoscopy), a stool chart maintained by nursing staff would demonstrate significant variation in bowel habit. It would be inappropriate to request this for assessment purposes, but this should not preclude the Delegate from awarding an appropriate rating, should such testing be available and provided.

In other words, the assessment criteria require objective testing showing objective signs of disease. Without this, a rating cannot be awarded. However, due to the nature of the testing, delegates should not push a client to undertake this testing.

Case 4. A 20 year old female recruit, living on base, reports daily 7/10 abdominal pain and constipation since enlistment. She has required 1-2 days off from work each month. After investigation of gynaecological pathology and a colonoscopy revealed no abnormalities, a diagnosis of IBS is made. The recruit commenced a low FODMAP diet and believes this has helped.

Discussion. This is a typical DVA client with IBS. However, the reported symptoms are not consistent with the functional impact and treatment has been self-prescribed.

Text Box: Likely PIG Impairment Rating - 0% WPI. While the symptoms appear more severe than case 1, given the inconsistencies in this case, it would be inappropriate to award a rating of 10% without quality objective evidence. Likely GARP Impairment Rating - GARP rating would be 2% WPI per table 6.1.3. Likely AMA Impairment Rating – 0-9% WPI per table 6-4.

There are inconsistencies in the clinical picture in case 4. While there is some dietary modification, and moderate symptoms, it is not clear that a rating of 10% is appropriate. In this context, truly objective evidence provided by a veteran’s treating Specialist may be sufficient in increase the rating to 10%, but it should not be assumed that such evidence exists.

Case 5a. A 45 year old female veteran presents with abdominal pain on most days, worse after meals. She had 4-5 episodes of diarrhoea every day, with no mucus. Gastroscopy and colonoscopy, including biopsy of colon, revealed no abnormality. A diagnosis of IBS was made by a Gastroenterologist. In conjunction with a dietitian, an exclusion diet was prescribed. Escitalopram was prescribed. This combination of treatments reduced the frequency of loose stools to once daily, but there was an increase in bloating and the severity of abdominal pain. The veteran preferred to manage the pain rather than frequent bowel actions so no further changes were made and the opinion of the Gastroenterologist was that the condition could not be improved further.

Discussion. This is a moderately severe case of IBS which has partially responded to treatment.

Text Box: Likely PIG Impairment Rating - 0% as there is no objective evidence of disease currently present. However, this case is clearly more severe than the others described, and there are no inconsistencies or suspicions with the clinical presentation. There should be scope to award a rating of 15% in this case, at the discretion of the delegate, but once again some objective testing must be undertaken. If mucus was present in the stool and observed by the assessing doctor, this would be an objective finding. Likely GARP Impairment Rating - GARP rating would be 10-20% per table 6.1.8. Likely AMA Impairment Rating – 0-9% WPI per table 6-4.

Case 5b. The veteran subsequently reports that she partook a trial of a new treatment for IBS. As part of the trial, she underwent formal testing of her gastro-intestinal transit time, the gut microbiota, and intestinal neurological testing. The findings are consistent with IBS and markedly different to normal function.

Discussion. This is a moderately severe case of IBS which has partially responded to treatment.

Text Box: Likely PIG Impairment Rating - With this new information, and the level of impairment described, a rating of 25% would be both warranted and defensible. Likely GARP Impairment Rating - GARP rating would be 10-20% per table 6.1.8. Likely AMA Impairment Rating – 20-25% per table 6-4.