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.
DIGESTIVE
Case Study #
D1
D2
D3
D4
D5
D6
D7
Brief Description
Gastric ulcer
Hernia and spleen
Upper digestive tract
Perforated jejunum
Abdominal tumour
Pancreatitis
Ruptured pancreas
Primary Body System
Digestive
Digestive
Digestive
Digestive
Digestive
Digestive
Digestive
Secondary Body System
Upper Limb
Spine
Spine
Spine
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
Any queries in respect of the methodology used in assessing permanent impairment may be directed
to the WPI e-mail enquiry service at [email protected]. This service is operated by the
Injury Management Branch of the MAA who are responsible for the content and publication of the
MAA Permanent Impairment Guidelines.
Any queries in respect of the methodology used in assessing permanent impairment may be directed
to the WPI e-mail enquiry service at [email protected]. This service is operated by the
Injury Management Branch of the MAA who are responsible for the content and publication of the
MAA Permanent Impairment Guidelines.
Panel Decision
Any queries in respect of the methodology used in assessing permanent impairment may be directed
to the WPI e-mail enquiry service at [email protected]. This service is operated by the
Injury Management Branch of the MAA who are responsible for the content and publication of the
MAA Permanent Impairment Guidelines.
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.
Any queries in respect of the methodology used in assessing permanent impairment may be directed
to the WPI e-mail enquiry service at [email protected]. This service is operated by the
Injury Management Branch of the MAA who are responsible for the content and publication of the
MAA Permanent Impairment Guidelines.
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
Any queries in respect of the methodology used in assessing permanent impairment may be directed
to the WPI e-mail enquiry service at [email protected]. This service is operated by the
Injury Management Branch of the MAA who are responsible for the content and publication of the
MAA Permanent Impairment Guidelines.
Any queries in respect of the methodology used in assessing permanent impairment may be directed
to the WPI e-mail enquiry service at [email protected]. This service is operated by the
Injury Management Branch of the MAA who are responsible for the content and publication of the
MAA Permanent Impairment Guidelines.
Panel Decision
Any queries in respect of the methodology used in assessing permanent impairment may be directed
to the WPI e-mail enquiry service at [email protected]. This service is operated by the
Injury Management Branch of the MAA who are responsible for the content and publication of the
MAA Permanent Impairment Guidelines.
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 102 –
107 of AMA4 Guidelines.
Any queries in respect of the methodology used in assessing permanent impairment may be directed
to the WPI e-mail enquiry service at [email protected]. This service is operated by the
Injury Management Branch of the MAA who are responsible for the content and publication of the
MAA Permanent Impairment Guidelines.
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 322 – 333 of AMA4 to determine a
final WPI of 14%.
Any queries in respect of the methodology used in assessing permanent impairment may be directed
to the WPI e-mail enquiry service at [email protected]. This service is operated by the
Injury Management Branch of the MAA who are responsible for the content and publication of the
MAA Permanent Impairment Guidelines.
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
Any queries in respect of the methodology used in assessing permanent impairment may be directed
to the WPI e-mail enquiry service at [email protected]. This service is operated by the
Injury Management Branch of the MAA who are responsible for the content and publication of the
MAA Permanent Impairment Guidelines.
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 205 -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
AMA Guides/
MAA Guidelines
References
(chapter/
page/table)
Stabilise
d
(YES/NO)
Current
%WPI*
Digestive
System
Chapter 10, Page
239, Section 10.4
and Table 2.
MAA Guidelines
Chapter 8,
Sections 8.18 and
8.19, Page51
Yes
25%
%WPI*
from preexisting
OR
subseque
nt causes
Nil
%WPI*
due to
motor
accident
25%
* %WPI = percentage whole person impairment
Any queries in respect of the methodology used in assessing permanent impairment may be directed
to the WPI e-mail enquiry service at [email protected]. This service is operated by the
Injury Management Branch of the MAA who are responsible for the content and publication of the
MAA Permanent Impairment Guidelines.
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%.
Any queries in respect of the methodology used in assessing permanent impairment may be directed
to the WPI e-mail enquiry service at [email protected]. This service is operated by the
Injury Management Branch of the MAA who are responsible for the content and publication of the
MAA Permanent Impairment Guidelines.
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 4th edition, page 10/245. Chapter 10.8 Pancreas.
“Symptoms and signs of an impairment of pancreatic function including, but
Any queries in respect of the methodology used in assessing permanent impairment may be directed
to the WPI e-mail enquiry service at [email protected]. This service is operated by the
Injury Management Branch of the MAA who are responsible for the content and publication of the
MAA Permanent Impairment Guidelines.
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.
AMA Guides/
Stabilised
MAA
(YES/NO)
Guidelines
References
(chapter/
page/table)
Upper gastroTable 2, page Yes
intestinal tract
10/239 Class I
(pancreas) – 0%-9% of
diarrhoea
WPI
* %WPI = percentage whole person impairment
Current
%WPI*
5%
%WPI* from
pre-existing
OR
subsequent
causes
0
%WPI* due to
motor
accident
5%
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%.
Any queries in respect of the methodology used in assessing permanent impairment may be directed
to the WPI e-mail enquiry service at [email protected]. This service is operated by the
Injury Management Branch of the MAA who are responsible for the content and publication of the
MAA Permanent Impairment Guidelines.
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 4th 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.
Any queries in respect of the methodology used in assessing permanent impairment may be directed
to the WPI e-mail enquiry service at [email protected]. This service is operated by the
Injury Management Branch of the MAA who are responsible for the content and publication of the
MAA Permanent Impairment Guidelines.
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
1.
Pancreas
AMA Guides/
MAA
Guidelines
References
(chapter/
page/table)
Stabilised
(YES/NO)
Chapter 10, Yes
Table2
Current
%WPI*
24
%WPI* from
pre-existing
OR
subsequent
causes
0
%WPI* due to
motor
accident
24
* %WPI = percentage whole person impairment
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%.
Any queries in respect of the methodology used in assessing permanent impairment may be directed
to the WPI e-mail enquiry service at [email protected]. This service is operated by the
Injury Management Branch of the MAA who are responsible for the content and publication of the
MAA Permanent Impairment Guidelines.