The following case studies relate to injuries to the Digestive System.

Transcription

1 Digestive System The following case studies relate to injuries to the Digestive System. More detailed information regarding the assessment of injuries to the digestive system may be found at Chapter 8 of the MAA s Permanent Impairment Guidelines and Chapter 10 of the AMA4 Guidelines. The Motor Accidents Authority of NSW makes no warranties or representation about the accuracy or completeness of the information contained in these Case Studies. It should be noted that the information contained herein is not provided as a substitute for legal advice.

2 DIGESTIVE Case Study # Brief Description Primary Body System Secondary Body System D1 Gastric ulcer Digestive Upper Limb D2 Hernia and spleen Digestive D3 Upper digestive tract Digestive Spine D4 Perforated jejunum Digestive Spine D5 Abdominal tumour Digestive D6 Pancreatitis Digestive Spine D7 Ruptured pancreas Digestive

3 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 13 July 1950 Date of Motor Accident: 20 April 2005 Injuries: Stomach ulcer due to anti-inflammatory medication Left shoulder traumatic capsulitis, soft tissue injury Neck aggravation of degenerative change Panel Deliberations

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6 Injuries: Right Inguinal Hernia Spleen Bleeding A 33-year-old man was a front seat passenger in a head-on collision. In addition to injuries to his back, neck and foot, he sustained injuries to his spleen and developed a right inguinal (groin) hernia and deep venous thrombosis (DVT) in his right leg. He was not admitted to hospital but bed rest was recommended. He later developed a pulmonary embolus (blockage of the pulmonary artery by foreign matter or by a blood clot). CT scans at that time showed some bleeding around the spleen. The spleen bleeding was monitored and resolved without specific treatment. He took an antiblood clotting drug for six months for the DVT. The claimant also noted swelling and pain in his right groin and ultrasound scans showed a small indirect right inguinal hernia. Clinical Examination At assessment, the claimant reported pain in his right foot, back and groin. His back and groin pain were aggravated by bending, lifting and twisting. His neck pain had largely resolved. There were no apparent residual symptoms from the spleen bleeding or the DVT in his right calf. Physical examination of the abdomen showed a small right inguinal hernia consistent with seat belt strain across the abdomen. The abdomen showed slight swelling and there was minimal cough impulse palpable in the right groin. His penis and testes were normal. The WPI was assessed using Classes of Hernia-related Impairment, Table 7 AMA 4 (page 247) and clause 8.20 of the MAA Guides which specifically state Table 7 (p 247, AMA 4): In classes 1 and 2 the first criterion must be present together with the second or third criterion. In class 3 all three criteria must be present. The Claimant fulfilled the criteria for Class 1 (0% - 9%) in that he had: A palpable defect in supporting structures of the abdominal wall; AND Slight protrusion at the site of defect with increased abdominal pressure that was readily reducible; OR Occasional mild discomfort at the site of the defect, but not precluding normal activity. Conclusion The groin hernia was allocated 3%WPI within this class range. The claimant was also assessed in relation to the other injuries sustained in the motor vehicle accident.

7 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 12 August 1962 Date of Motor Accident: 29 March 2000 Injuries: Reflux oesophagitis Back L4/5 annular disc bulge, soft tissue injury Neck C3/4 disc prolapse, whiplash Panel Deliberations

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10 Injuries: Perforated Jejunum Fracture of transverse process at L2 A 7 year old child was a back seat passenger in a car involved in a rear end collision. Injuries sustained included a fracture of the transverse process at L2 and a perforated jejunum. The jejunum is part of the small intestine. The perforated jejunum formed an inflammatory mass and adhesive bowel obstruction followed. The claimant was admitted to hospital and underwent surgery to the bowel. Ongoing reviews with the Treating General Surgeon occurred and a further two laparotomies were carried out. Clinical Examination Full range of movement was present in her lumbar spine, no guarding or spasm was observed by the Assessor. The fracture to the transverse process at L2 was confirmed on X-ray. No treatment was currently required although further surgery to the bowel may be required in the future. The claimant s weight was within normal range for her height and build. Impairment to the upper digestive tract, including the oesophagus, stomach, duodenum, small Intestine and pancreas is assessed using Table Two, page 239 of AMA4. Four impairment classes exist and the criteria for Class 1 are: Criteria for Class 1(0 9%) 1. Symptoms or signs of upper digestive tract disease present: or anatomic loss or alteration; and 2. Continuous treatment is not required and 3. Weight can be maintained at a desirable level or 4. There are no sequelae after surgical procedures. The injury to the Upper Digestive Tract falls into Class 1 (0-9)%. The Assessor determined that for the abdominal injury the claimant was in the severe end of Class 1 and assessed 9%WPI. Additional impairments may be assigned for the scarring resulting from the surgeries. Lumbar Spine Impairment of the spine is assessed using the Diagnostic Related Estimates (DRE) model. The DRE categories for each level of the spine are described on pages of AMA4 Guidelines.

11 The claimant meets the structural inclusions for DRE Lumbosacral Category II. A spinous or transverse process fracture was sustained as a result of the MVA. WPI as a result of the injury to the Lumbar spine is 5%. Impairments as a result of the injury to the lumbar spine and upper digestive tract are combined using the Combination Tables on pages of AMA4 to determine a final WPI of 14%.

12 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 5 August 1967 Date of Motor Accident: 27 December 2003 Injuries: Abdomen and bowel soft tissue injury with large intra-abdominal tumour Clinical Findings The claimant was a rear seat passenger in a motor vehicle involved in an accident. He had suffered seatbelt injuries, was taken by ambulance to Hospital where he was admitted, operation performed and he was found to be suffering from a laceration and perforation of the duodenum. The perforation was closed and the post-operative course was uneventful. A short time after his discharge from hospital he developed severe abdominal pain, was readmitted and found to be suffering from peritonitis. A second operation was necessary. At operation the closure of the perforation was found to be intact, the abdominal cavity was cleansed of any irritant or infected material and then inspected for other possible sources of contamination. Recovery was satisfactory. He then found a tender lump in the right lower abdomen (inguinal region). In the investigations, CT Scan, prior to surgery a tumour was discovered in the left upper abdomen. Laparoscopy and biopsy was performed and, after thorough histological and associated assessment of the specimen, it was considered that the tumour was a Desmoid tumour. On examination, the claimant presented as a tall, well nourished person, in no apparent distress. He was 190 cm tall and weighed 96.6 kg. The operative abdominal scars were noted. Significant findings: The abdomen was slightly full and rounded, but not distended; A visible and palpable mass was situated in the left upper abdomen; The mass (tumour) clinically measured 13 cm in maximum diameter. The tumour was firm and tender on palpation and painful, when moved with pressure exerted from the loin; The tumour palpated was consistent with that identified on the imaging studies; and There was no visible or palpable evidence of distended loops of bowel or of ascites (fluid collection within the abdominal cavity). Three factors have been identified in the development of Desmoid tumours: Genetic; Endocrine; and Physical, including trauma. As there was no evidence of any familial

13 genetic factor and the development of the tumour following trauma with rupture of the duodenum, that is in close proximity to the root of the mesentery, and that the claimant also underwent two abdominal surgical procedures, made necessary by the motor accident, all the evidence is that the motor accident was either the cause, or a significant contributing factor to the development, of the Desmoid tumour. Panel Findings Impairments of the upper digestive tract (including small intestine) are addressed in the AMA Guides, 4th Edition, Chapter 10, Page 239, Section 10.4 and Table 2. There is anatomical abnormality (tumour) in the small bowel mesentery. Continuous medication is required. The symptoms, particularly pain with increased activity, and signs, abdominal tumour, are not completely controlled by drugs (medical treatment) and avoidance of some foods such as eggs and prawns. Weight is maintained at above the desirable level. Class 3 applies -- range 25% --49%. The panel considered that 25% is appropriate. Alternately as malignant tumours are not specifically addressed in either the MAA Guidelines or the AMA Guides, 4th Edition, an appropriate analogy of relevant impairment rating is AMA Guides, 4th Edition, Chapter 7 Section 7.5, Page Criteria for Evaluating Permanent Impairment of White Blood Cell Systems because malignant lymphomas require continuing monitoring and continuous or intermittent medical treatment to control the condition as is the situation for the claimant. A person belongs in Class 2 when (1) there are symptoms and signs of leucocyte (substitute large tumour) abnormality; and (2) although continuous treatment is required most of the activities of daily living can be performed. In view of the fact that continuous medication has not caused significant resolution of the tumour and the range is from 15% to 30% a whole person impairment of 25% is considered by the panel to be appropriate. The whole person permanent impairment of the injuries caused by the accident was calculated as follows: Body Part or System Digestive System AMA Guides/ MAA Guidelines References (chapter/ page/table) Chapter 10, Page 239, Section 10.4 and Table 2. MAA Guidelines Chapter 8, Sections 8.18 and 8.19, Page51 Stabilise d (YES/NO) Current %WPI* %WPI* from preexisting OR subseque nt causes Yes 25% Nil 25% %WPI* due to motor accident * %WPI = percentage whole person impairment

14 Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 25%. Therefore the total whole person impairment is greater than 10%.

15 Injuries: Abdominal traumatic pancreatitis trauma Manubria (breast bone) fracture Ribs fracture 5-8 on the left side. Ribs fracture 2 on the right side. The accident was a high speed head-on collision. The claimant was a rear seat passenger, seated behind the driver. She was struck from behind in the back of the head and neck by luggage propelled forward. She believes she sustained a fracture of her sternum, fracture of both right and left ribs, crushing of her pancreas and dislodgement of her left breast. She also was diagnosed as having a torn bowel causing internal bleeding but did not require operation but she was given a blood transfusion. Current Symptoms She has persistent pain in and about her right sternum. Her left breast is uncomfortable and occasionally painful and she is aware of depression in the upper medial quadrant of the left breast following her motor accident. She is troubled by intermittent epigastric pain which occasionally radiates through to her back. It is not provoked by eating and tends to occur spontaneously. She finds that lying on her left side provides relief. It is not a burning pain but sharp in nature. She has been troubled with intermittent diarrhoea or possible steatorrhoea and this has been investigated and a colonoscopy which was performed one month ago was reported as normal. Clinical Examination The claimant was a 37 year old woman who appeared to move without difficulty. Her height was 5 feet 1 inches. She weighed 61kg. Head & Neck/Cervical Spine There was some stiffness of movement but this was not restricted in any direction. There was no paravertebral muscular spasm. Chest No abnormality was found in her chest although she complained of discomfort when pressure was applied directly to her sternum. Abdomen Tenderness in the epigastrium but no abnormal mass. Hernial region sound. Whole Person Impairment See AMA 4 th edition, page 10/245. Chapter 10.8 Pancreas. Symptoms and signs of an impairment of pancreatic function including, but

16 are not limited to, pain, anorexia, nausea, vomiting, diarrhoea, steatorrhoea, weight loss, muscle wasting, jaundice, diabetes mellitus, and debility. They can also suffer an impairment related to endocrine functioning. Also see Table 2, page 10/239. Classes of Impairment of the Upper Digestive Tract. Class I: 0%-9% impairment of the whole person Symptoms or signs of upper digestive tract disease are present, or there is anatomic loss or alteration, and continuous treatment is not required, and weight can be maintained at desirable level. It is considered that the claimant s diarrhoea and possible steatorrhoea fall into this category with an estimated 5% impairment of the whole person. Degree of Whole Person Impairment (WPI) of Injuries that are PERMANENT Body Part or System 1. Upper gastrointestinal tract (pancreas) - diarrhoea AMA Guides/ MAA Guidelines References (chapter/ page/table) Table 2, page 10/239 Class I 0%-9% of WPI Stabilised (YES/NO) * %WPI = percentage whole person impairment Current %WPI* %WPI* from pre-existing OR subsequent causes Yes 5% 0 5% %WPI* due to motor accident Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 5%.

17 This matter was subject to review by a Medical Review Panel. These are the Review Panel s findings. Claimant s Date of Birth: 27 January 1989 Date of Motor Accident: 14 March 2002 Injuries: Ruptured pancreas Clinical Findings The claimant had been crushed between a car door and the side of the house when the vehicle was reversing. She had sustained abdominal injuries, including a ruptured pancreas. An urgent laparoscopy was performed and the distal half of her pancreas was removed. The claimant was questioned about her current symptoms and diet. She reported abdominal pain on a daily basis, which was crampy in nature. The pain was mainly in the upper abdomen and did not appear to have any precipitating factor. She treated this pain with panadol as required. With respect to diet she has modified her intake since the accident. She no longer eats red meat but does eat chicken and fish. She also eats salads, vegetables and fruit without difficulty but in small amounts. She avoids spicy foods, dairy foods and fatty foods as these lead to abdominal bloating, cramps and eventually diarrhoea. She reports that after such food her bowel motions tend to float and are very offensive. She reports though that if she sticks to a low fat diet and does not eat large portions that her bowel motions are reasonably normal. At examination the claimant was noted to be extremely thin. She was 153cm tall and weighed 37.7kgs. She reported that she has attempted to put on weight but has been unable to do so. Examination of her abdomen revealed a well-healed midline scar, which was not pigmented, tender or attached to deeper structures. Mild tenderness was present over a previous drain scar in the right upper quadrant. Panel Decision The panel considered that the most appropriate table to assess the pancreatic injury was Table 2 on page 239 of the 4 th Edition of the AMA Guides. This table deals with impairment of the upper digestive tract including the pancreas. The panel did not believe that the Endocrine Chapter (Chapter 12) was appropriate, as the claimant has no signs or symptoms of diabetes. The panel considered the criteria for placing an individual into one of the classes of Table 2 (Chapter 10, page 239). o The claimant does have anatomic loss with surgical removal of the distal half of the pancreas.

18 o o The claimant currently has a Body Mass Index of 16.1 and is 19% below her optimum weight (Body Mass Index of 20). The claimant is currently not on medication for nutritional deficiency but definitely does have symptoms and signs of nutritional deficiency. The panel agreed that the first criteria would have been met for all classes from Table 2. The panel also agreed that the third criteria was met for Classes 2 & 3 of Table 2. With respect to criteria 2 the panel believed that the claimant does have appropriate dietary restrictions and does require medication for control of symptoms and signs of nutritional deficiency. Currently the claimant is not on medication for nutritional deficiency but the panel strongly believed that she should be on medication. The panel believed that her dietary restrictions, inability to put on weight and bowel symptoms are indicative of pancreatic insufficiency which should be controlled by enzyme replacement medication. The panel believed that from the first and third criteria that she could have been placed in Class 3 from Table 2. From the second criteria she can be placed in Class 2 and may even be borderline for Class 3. The panel concluded that the most appropriate assessment for her pancreatic injury was at the upper end of Class 2, 24% WPI. The whole person permanent impairment of the injuries caused by the accident was calculated as follows: Body Part or System AMA Guides/ MAA Guidelines References (chapter/ page/table) 1. Pancreas Chapter 10, Table2 Stabilised (YES/NO) * %WPI = percentage whole person impairment Current %WPI* %WPI* from pre-existing OR subsequent causes Yes %WPI* due to motor accident Determination Regarding the Degree of Whole Person Impairment of the Injured Person as a Result of the Injuries Caused by the Motor Accident The total percentage whole person permanent impairment for assessed injuries caused by the motor accident is 24%. Therefore the total whole person impairment is greater than 10%.