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Medical assessor guidance note 10

Digestive system: Stomach and Duodenum Impairment

Assessment of oesophagus, stomach and duodenum

This material is issued by the Motor Accidents Authority under s.65(2) of the Motor Accidents Compensation Act 1999 (the  Act) in the interests  of promoting  accurate and consistent medical assessments  under the Act. The interpretation provided here is not legally binding but represents the clinically recommended interpretation in an area where more than one interpretation of existing provisions may be possible. This recommended interpretation is publically available. Any medical assessment which does not adopt this interpretation should be accompanied by clinical justification for the interpretation adopted, supported by full, robust reasons.

References

The American Medical Association Guides to the Evaluation of Permanent Impairment, 4th edition (AMA 4 Guides): Chapter 10 Table 2, page 239.

The Motor Accidents Authority Permanent Impairment Guidelines – Guidelines for the assessment of permanent impairment of a person injured as a result of a motor vehicle accident 1 October 2007 (MAA Guidelines): Chapter 8 page 50.

Background

Impairment of the upper digestive tract is assessed using Table 2. The difference between Class 1 and Class 2 (Table 2) relates to the requirement for dietary restriction and drugs, and the provision that ‘Loss of weight below “desirable weight” [as defined in Table 1, page 237] does not exceed 10%’.

Issue requiring clarification

The intention of the loss of weight provision as a mandatory requirement for Class 2 is unclear. It is suggested that a person who fulfils the first two criteria of Class 2 but who does not show any weight loss should be included in Class 2 as they are clearly more impaired than a person in Class 1 who does not require continuous treatment. The criteria are ambiguous as to whether someone with no weight loss can be included in Class 2.

Preferred interpretation

The provision in Class 2 regarding weight loss is interpreted to mean that where there is weight loss, this should not exceed 10% below desirable weight as defined in Table 1. In a case where weight loss is zero, this can be classified into Class 2 providing all other criteria are met.

Justification for preferred interpretation

A person who fulfils the first criterion of Class 2 and who requires continuous treatment but is able to maintain their desirable weight may not meet the criteria for either Class 1 or Class 2 as currently defined.

Applying the preferred interpretation, a person with ‘Symptoms and signs of organic upper digestive tract disease’ or ’anatomic loss or alteration’ who requires ‘Appropriate dietary restrictions and drugs’ for control of ‘symptoms, signs or nutritional deficiency’, but who has no weight loss, would be assessed as Class 2.

The preferred interpretation is to promote consistency in the interpretation of Class 1 and Class 2 (Table 2) in assessments of the oesophagus, stomach, duodenum, small intestine and pancreas.

Case examples

1. Class 1 - 0% WPI No symptoms

The claimant developed intermittent nausea and epigastric pain, as well as intermittent pain behind his sternum, which was described as burning and associated with intermittent acid tasting fluid reflux into his mouth, related to use of Voltaren.

Gastroscopy revealed ulcerative gastritis and gastro-oesophageal reflux and there was no evidence of Helicobacter pylori infection. The claimant was advised to cease Voltaren and prescribed a proton pump inhibitor to restrict the production of acid and pepsin by the stomach. This treatment was highly effective and the claimant no longer had symptoms of gastro-oesophageal reflux or upper abdominal pain and nausea. He ceased the proton pump inhibitor. He no longer uses anti-inflammatory medications. Abdominal examination was normal. He was assessed as Class 1 because the symptoms have resolved and there are no abnormal signs on examination. As he has no further symptoms or abnormal signs on abdominal examination, this was assessed at 0% WPI.

2. Class 1 - 1% WPI Symptoms but no signs

Claimant had intermittent epigastric pain and occasional symptoms of gastro-oesophageal reflux related to use of over-the- counter anti-inflammatory medications. He was still using regular anti-inflammatory medication for pain at the time of assessment and taking Nexium (a proton pump inhibitor) intermittently. Abdominal examination was normal and he had put on weight. He had not had any gastrointestinal investigations.

At the time of assessment the claimant had typical symptoms of gastro-oesophageal reflux, but no signs of upper digestive tract disease; there was no anatomical loss or alteration; continuous treatment was not required and he had not suffered weight loss, in fact his weight had increased. Class 2 was not applicable because he only had upper gastrointestinal tract symptoms but not signs. The symptoms were relatively infrequent, but severe enough to require intermittent treatment with a proton pump inhibitor. With consideration given to the example of Class 1 impairment on page 236 of the AMA 4Guides (an uncomplicated hiatus hernia assessed as 0% WPI) and as the disorder was symptomatic, the injury was assessed as 1% WPI.

3. Class 2 - 12% WPI Symptoms and signs but no weight loss. Treatment required

The claimant had reflux oesophagitis and ulcerative gastritis on gastroscopy requiring continuing treatment with proton pump inhibitor medication, related to continued use of anti-inflammatory medications for pain. She had dyspepsia and upper abdominal pain every day, increased by eating heavy meals and relieved by eating soup. There was no burning pain behind the sternum and no acid reflux into the mouth. There had been no weight loss. The claimant continued to take proton pump inhibitor medication as well as an anti-inflammatory medication. The Assessor found the anti-inflammatory medications prescribed to treat the injuries due to the MVA caused the oesophagitis and gastritis.

The Assessor found symptoms of upper digestive tract disease and anatomic alteration with evidence of oesophagitis, now asymptomatic and symptomatic gastritis at gastroscopy. There was need for continuous treatment but no weight loss. This satisfied two of the criterion for Class 2 impairment and as per Guidance Note 10, with the first 2 criteria met, even though there was zero weight loss, this can be classified at Class 2. This was assessed at the lower end of the scale at 12% because the impairment would be less than that given in the example given for Class 2 on page 238 of the AMA 4 Guides.

Re -issued by:

Injury Strategy Branch

07/2015

Further information

Contact us at wpienquiry@maa.nsw.gov.au.