Statement of Principles concerning GASTRIC ULCER AND GASTRIC EROSION (Reasonable Hypothesis) (No. 51 of 2024) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986. Dated 21 June 2024. Professor Terence Campbell AM Chairperson by and on behalf of The Repatriation Medical Authority 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 gastric ulcer and gastric erosion (Reasonable Hypothesis) (No. 51 of 2024). 2 Commencement This instrument commences on 23 July 2024. 3 Authority This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986. 4 Repeal The Statement of Principles concerning gastric ulcer and duodenal ulcer No. 61 of 2015 (Federal Register of Legislation No. F2015L00657) made under subsection 196B(2) and (8) of the VEA is repealed. 5 Application This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004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 gastric ulcer and gastric erosion and death from gastric ulcer and gastric erosion. Meaning of gastric ulcer and gastric erosion (2) For the purposes of this Statement of Principles, gastric ulcer and gastric erosion: (a) means a non-malignant disruption in the mucosal surface of the stomach; and (b) includes ulcers or erosions due to gastric foreign bodies; and (c) excludes: (i) acute haemorrhagic gastritis; and (ii) stomach perforations from external trauma such as stabbing, explosive blast injury or gunshot injury. Note: A gastric erosion is a disruption in the mucosal surface of the stomach above the lamina propria, and a gastric ulcer is a disruption in the mucosal surface of stomach that extends past the lamina propria and through the muscularis mucosa into the submucosa. (3) While gastric ulcer and gastric erosion attracts ICD‑10‑AM code K25 in applying this Statement of Principles the meaning of gastric ulcer and gastric 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 gastric ulcer and gastric erosion (5) For the purposes of this Statement of Principles, gastric ulcer and gastric erosion, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's gastric ulcer and gastric erosion. Note: terminal event is defined in the Schedule 1 – Dictionary. 8 Basis for determining the factors The Repatriation Medical Authority is of the view that there is sound medical-scientific evidence that indicates that gastric ulcer and gastric erosion and death from gastric ulcer and gastric erosion can be related to relevant service rendered by veterans, members of Peacekeeping Forces, 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 as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting gastric ulcer and gastric erosion or death from gastric ulcer and gastric erosion with the circumstances of a person's relevant service: (1) being a prisoner of war before clinical onset or clinical worsening; (2) having Helicobacter pylori infection of the stomach at the time of clinical onset or clinical worsening; (3) having an infection of the gastric mucosa by one of the following organisms: (a) Anisakis simplex (causing anisakiasis); (b) cytomegalovirus; (c) herpes simplex virus; (d) fungi (such as Candida species or Mucormycetes); (e) Helicobacter heilmannii; (f) Mycobacterium tuberculosis; (g) Strongyloides stercoralis (causing strongyloidiasis); or (h) Treponema pallidum (causing syphilis); at the time of clinical onset or clinical worsening; (4) having a critical illness or injury within the 30 days before clinical onset or clinical worsening; Note: critical illness or injury is defined in the Schedule 1 - Dictionary. (5) undergoing a course of radiotherapy for cancer, where the stomach or duodenum was in the field of radiation, within the one year before clinical onset or clinical worsening; (6) having received a cumulative equivalent dose of at least 10 sieverts of ionising radiation to the stomach or duodenum within the one year before clinical onset or clinical worsening; Note: cumulative equivalent dose is defined in the Schedule 1 - Dictionary. (7) undergoing 90Yttrium microsphere therapy for primary and metastatic liver tumours, within the one year before clinical onset or clinical worsening; (8) 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; (9) having partial gastrectomy within the 5 years before clinical onset or clinical worsening of gastric ulcer or gastric erosion; (10) having endoscopic mucosal resection or endoscopic sub-mucosal dissection of the gastric mucosa at the time of clinical onset or clinical worsening; (11) having bariatric surgery involving sleeve gastrectomy or gastric banding within the 5 years before clinical onset or clinical worsening; (12) having a gastrin-secreting tumour at the time of clinical onset or clinical worsening; (13) smoking at least 10 cigarettes a day for at least one year within the 2 years before clinical onset or clinical worsening; (14) 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 8 days, within the 3 months before clinical onset or clinical worsening; (15) having a solid organ or bone marrow transplant before clinical onset or clinical worsening; (16) 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. (17) being treated with one of the following drugs or class of drugs within the 7 days before 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); (18) 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; (19) 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; (20) experiencing one of the following category 1A stressors within the 3 months before clinical onset or clinical worsening: (a) experiencing a life-threatening event; (b) being subject to a serious physical attack or assault including rape and sexual molestation; or (c) being threatened with a weapon, being held captive, being kidnapped, or being tortured. (21) having posttraumatic stress disorder within the 3 months before the clinical onset or clinical worsening; (22) being diagnosed by a registered medical practitioner with anxiety disorder, depressive disorder, bipolar disorder, obsessive compulsive disorder or panic disorder at the time of clinical onset or clinical worsening; (23) having cirrhosis of the liver at the time of clinical onset or clinical worsening; (24) 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 gastric ulcer; Note 1: The bleeding of a gastric 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. (25) having diabetes mellitus at the time of clinical onset or clinical worsening; (26) having Crohn disease (a type of inflammatory bowel disease) at the time of clinical onset or clinical worsening; (27) 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; or (e) uraemic gastritis; Note 1: systemic mastocytosis is defined in the Schedule 1 – Dictionary. Note 2: Uraemic gastritis is a gastritis that occurs in the setting of poorly treated or untreated chronic renal failure. (28) having chronic obstructive pulmonary disease at the time of bleeding of a gastric ulcer; Note: The bleeding of a gastric ulcer is considered to be a clinical worsening. (29) inability to obtain appropriate clinical management for gastric ulcer and gastric erosion. 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, gastric ulcer and gastric erosion where the person's gastric ulcer and gastric 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(2) 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. cumulative equivalent dose means the total dose of ionising radiation received by the particular organ or tissue. The formula used to calculate the cumulative equivalent dose allows doses from multiple types of ionising radiation to be combined, by accounting for their differing biological effect. The unit of equivalent dose is the sievert. For the purposes of this Statement of Principles, the calculation of cumulative equivalent dose excludes doses received from normal background radiation, but includes therapeutic radiation, diagnostic radiation, cosmic radiation at high altitude, radiation from occupation-related sources and radiation from nuclear explosions or accidents; gastric ulcer and gastric erosion—see subsection 7(2). MRCA means the Military Rehabilitation and Compensation Act 2004. relevant service means: (a) operational service under the VEA; (b) peacekeeping service under the VEA; (c) hazardous service under the VEA; (d) British nuclear test defence service under the VEA; (e) warlike service under the MRCA; or (f) non-warlike service under the MRCA. Note: MRCA and VEA are 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.