{"id":"F2024L00749","name":"Statement of Principles concerning duodenal ulcer and duodenal erosion (Reasonable Hypothesis) (No. 49 of 2024)","slug":"statement-of-principles-concerning-duodenal-ulcer-and-duodenal-erosion-reasonable-hypothesis-no-49-o","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":442445,"registerId":"F2024L00749-fast-fetch-1775957451452","compilationNumber":null,"startDate":"2026-04-12","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"1","sectionType":"section","heading":"Statement of Principles concerning duodenal ulcer and duodenal erosion (Reasonable Hypothesis) (No. 49 of 2024)","content":"---\nmeta-content-style-type: text/css\nmeta-content-type: application/xhtml+xml; charset=utf-8\n---\n\n?xml version=\"1.0\" encoding=\"utf-8\" standalone=\"no\"?>\n\n\n\n \n\nStatement of Principles\n\nconcerning\n\nDUODENAL ULCER AND DUODENAL EROSION (Reasonable Hypothesis)\n\n(No. 49 of 2024)\n\nThe Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.\n\n \n\nDated 21 June 2024.\n\n \n\n \n\n \n\n \n\n \n\n \n\n \n\n|
Professor Terence Campbell AM
Chairperson
by and on behalf of
The Repatriation Medical Authority
|\n| --- |\n| |\n\n\n \n\n \n\n\nContents\n\n1 Name\n\n2 Commencement\n\n3 Authority\n\n4 Repeal\n\n5 Application\n\n6 Definitions\n\n7 Kind of injury, disease or death to which this Statement of Principles relates\n\n8 Basis for determining the factors\n\n9 Factors that must exist\n\n10 Relationship to service\n\n11 Factors referring to an injury or disease covered by another Statement of Principles\n\nSchedule 1 - Dictionary\n\n1 Definitions\n\n \n\n\n\n\n1 Name\n\nThis is the Statement of Principles concerning duodenal ulcer and duodenal erosion (Reasonable Hypothesis) (No. 49 of 2024).\n\n2 Commencement\n\n This instrument commences on 23 July 2024.\n\n3 Authority\n\nThis instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986.\n\n4 Repeal\n\nThe 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No. 61 of 2015 (Federal Register of Legislation No. F2015L00657) made under subsection 196B(2) and (8) of the VEA is repealed.\n\n5 Application\n\nThis instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies.\n\n6 Definitions\n\nThe terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.\n\n7 Kind of injury, disease or death to which this Statement of Principles relates\n\n(1) This Statement of Principles is about duodenal ulcer and duodenal erosion and death from duodenal ulcer and duodenal erosion.\n\nMeaning of duodenal ulcer and duodenal erosion\n\n(2) For the purposes of this Statement of Principles, duodenal ulcer and duodenal erosion:\n\n(a) means a non-malignant disruption in the mucosal surface of the duodenum; and\n\n(b) includes ulcers or erosions due to duodenal foreign bodies; and\n\n(c) excludes:\n\n(i) acute superficial mucosal erosions of the duodenum; and\n\n(ii) duodenal perforations from external trauma such as stabbing, explosive blast injury or gunshot injury;\n\nNote: A duodenal erosion is a disruption in the mucosal surface of the duodenum above the lamina propria, and a duodenal ulcer is a disruption in the mucosal surface of duodenum that extends past the lamina propria and through the muscularis mucosa into the submucosa.\n\n(3) While duodenal ulcer and duodenal erosion attracts ICD‑10‑AM code K26, in applying this Statement of Principles the meaning of duodenal ulcer and duodenal erosion is that given in subsection (2).\n\n(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.\n\nDeath from duodenal ulcer and duodenal erosion\n\n(5) For the purposes of this Statement of Principles, duodenal ulcer and duodenal erosion, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's duodenal ulcer and duodenal erosion.\n\nNote: terminal event is defined in the Schedule 1 – Dictionary.\n\n8 Basis for determining the factors\n\nThe Repatriation Medical Authority is of the view that there is sound medical-scientific evidence that indicates that duodenal ulcer and duodenal erosion and death from duodenal ulcer and duodenal 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.\n\nNote: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary.\n\n9 Factors that must exist\n\nAt least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting duodenal ulcer and duodenal erosion or death from duodenal ulcer and duodenal erosion with the circumstances of a person's relevant service:\n\n(1) being a prisoner of war before clinical onset or clinical worsening;\n\n(2) having Helicobacter pylori infection of the duodenum at the time of clinical onset or clinical worsening;\n\n(3) having an infection of the duodenal mucosa by one of the following organisms:\n\n(a) Anisakis simplex (causing anisakiasis);\n\n(b) cytomegalovirus;\n\n(c) herpes simplex virus;\n\n(d) fungi (such as Candida species or Histoplasma capsulatum);\n\n(e) Helicobacter heilmannii;\n\n(f) Mycobacterium tuberculosis;\n\n(g) Strongyloides stercoralis (causing strongyloidiasis); or\n\n(h) Treponema pallidum infection (causing syphilis);\n\nat the time of clinical onset or clinical worsening;\n\n(4) having a critical illness or injury within the 30 days before clinical onset or clinical worsening;\n\nNote: critical illness or injury is defined in the Schedule 1 - Dictionary.\n\n(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;\n\n(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;\n\nNote: cumulative equivalent dose is defined in the Schedule 1 - Dictionary.\n\n(7) undergoing 90Yttrium microsphere therapy for primary and metastatic liver tumours, within the one year before clinical onset or clinical worsening;\n\n(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;\n\n(9) having Roux-en-Y gastric bypass within the 5 years before clinical onset or clinical worsening of duodenal ulcer or duodenal erosion, where the ulcer or erosion occurred at the site of the surgical anastomosis;\n\n(10) having a gastrin-secreting tumour at the time of clinical onset or clinical worsening;\n\n(11) smoking at least 10 cigarettes per day, or the equivalent thereof in other tobacco products, for at least the 12 months before clinical onset or clinical worsening;\n\n(12) 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;\n\n(13) having a solid organ or bone marrow transplant before clinical onset or clinical worsening;\n\n(14) being treated with an antineoplastic agent within the 3 months before clinical onset or clinical worsening;\n\nNote: antineoplastic agent is defined in the Schedule 1 - Dictionary.\n\n(15) being treated with one of the following drugs or class of drugs within the 7 days before clinical onset or clinical worsening:\n\n(a) bisphosphonate, including alendronate;\n\n(b) chemotherapeutic agents delivered by hepatic arterial infusion; or\n\n(c) potassium chloride tablet (enteric coated or wax formulation);\n\n(16) being treated with one of the following drugs or class of drugs for at least 2 weeks, within the 3 months before clinical onset;\n\n(a) clopidogrel;\n\n(b) glucocorticoid, excluding topical or inhaled;\n\n(c) deferasirox;\n\n(d) nicorandil;\n\n(e) paracetamol of more than 2 grams daily; or\n\n(f) selective serotonin re-uptake inhibitors;\n\n(17) taking one of the following drugs or class of drugs for at least 2 weeks, within the 3 months before clinical worsening;\n\n(a) anticoagulants;\n\n(b) clopidogrel;\n\n(c) corticosteroids, excluding topical or inhaled;\n\n(d) lanthanum;\n\n(e) levodopa with benserazide or carbidopa;\n\n(f) methylnaltrexone;\n\n(g) nicotinic acid;\n\n(h) paracetamol of more than 2 grams daily;\n\n(i) pentoxifylline;\n\n(j) selective serotonin re-uptake inhibitors; \n\n(k) spironolactone;\n\n(l) tocilizumab;\n\n(m) tofacitinib; or\n\n(n) upadacitinib;\n\n(18) experiencing one of the following category 1A stressors within the 3 months before clinical onset or clinical worsening:\n\n(a) experiencing a life-threatening event;\n\n(b) being subject to a serious physical attack or assault including rape and sexual molestation; or\n\n(c) being threatened with a weapon, being held captive, being kidnapped, or being tortured.\n\n(19) having posttraumatic stress disorder within the 3 months before the clinical onset or clinical worsening;\n\n(20) 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;\n\n(21) having cirrhosis of the liver at the time of clinical onset or clinical worsening;\n\n(22) 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 duodenal ulcer;\n\nNote 1: The bleeding of a duodenal ulcer is considered to be a clinical worsening.\n\nNote 2: Alcohol consumption is calculated utilising the Australian Standard of 10 grams of alcohol per standard alcoholic drink.\n\n(23) having diabetes mellitus at the time of clinical onset or clinical worsening;\n\n(24) having Crohn disease (a type of inflammatory bowel disease) at the time of clinical onset or clinical worsening;\n\n(25) having one of the following medical conditions at the time of clinical onset or clinical worsening;\n\n(a) amyloidosis;\n\n(b) eosinophilic gastroenteritis;\n\n(c) sarcoidosis;\n\n(d) systemic mastocytosis; or\n\n(e) uraemic gastritis;\n\nNote 1: systemic mastocytosis is defined in the Schedule 1 – Dictionary.\n\nNote 2: Uraemic gastritis is a gastritis that occurs in the setting of poorly treated or untreated chronic renal failure.\n\n(26) having chronic obstructive pulmonary disease at the time of bleeding of a duodenal ulcer;\n\nNote: The bleeding of a dudenal ulcer is considered to be a clinical worsening.\n\n(27) inability to obtain appropriate clinical management for duodenal ulcer and duodenal erosion.\n\n10 Relationship to service\n\n(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.\n\n(2) The clinical worsening aspects of factors set out in section 9 apply only to material contribution to, or aggravation of, duodenal ulcer and duodenal erosion where the person's duodenal ulcer and duodenal erosion was suffered or contracted before or during (but did not arise out of) the person's relevant service.\n\n11 Factors referring to an injury or disease covered by another Statement of Principles\n\nIn this Statement of Principles:\n\n(1) if a factor referred to in section 9 applies in relation to a person; and\n\n(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;\n\nthen 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.\n\n \n\n \n\nSchedule 1 - Dictionary \n\nNote: See Section 6\n\n1 Definitions\n\nIn this instrument:\n\n antineoplastic agent means any of the following:\n\n(a) alkylating agents;\n\n(b) antimetabolites;\n\n(c) antineoplastic antibodies; or\n\n(d) kinase inhibitors.\n\n critical illness or injury means:\n\n(a) any physical injury or illness requiring mechanical ventilation support or admission to an intensive care unit;\n\n(b) acute renal tubular necrosis;\n\n(c) adult respiratory distress syndrome;\n\n(d) 2nd degree burns covering a total burn area of 50-70%, or 3rd degree burns covering an area >20% of total body surface;\n\n(e) disseminated intravascular coagulation;\n\n(f) multiple organ failure; or\n\n(g) septicaemia.\n\n 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;\n\n duodenal ulcer and duodenal erosion—see subsection 7(2).\n\n MRCA means the Military Rehabilitation and Compensation Act 2004.\n\n relevant service means:\n\n(a) operational service under the VEA;\n\n(b) peacekeeping service under the VEA;\n\n(c) hazardous service under the VEA;\n\n(d) British nuclear test defence service under the VEA;\n\n(e) warlike service under the MRCA; or\n\n(f) non-warlike service under the MRCA.\n\nNote: MRCA and VEA are defined in the Schedule 1 - Dictionary.\n\n systemic mastocytosis means a mast cell hyperplasia that is generally detected in the bone marrow, skin, gastrointestinal mucosa, liver or spleen.\n\n terminal event means the proximate or ultimate cause of death and includes the following:\n\n(a) pneumonia;\n\n(b) respiratory failure;\n\n(c) cardiac arrest;\n\n(d) circulatory failure; or\n\n(e) cessation of brain function.\n\n VEA means the Veterans' Entitlements Act 1986.\n\n \n\n \n","sortOrder":0}],"analysis":{"flash_summary_failed":{"failed":true,"reason":"Unauthenticated. Configure AI_GATEWAY_API_KEY or use a provider module. Learn more: https://ai-sdk.dev/unauthenticated-ai-gateway","source":"analysis-cron"},"kimi_summary":{"content_quality":"ok","complexity_score":6,"scope_assessment":{"changed":true,"description":"The original 2015 instrument covered both gastric (stomach) ulcers and duodenal ulcers together. This 2024 version narrows the scope to duodenal conditions only, suggesting a deliberate splitting of the previous combined instrument into separate, more specific documents. This allows for more precise medical criteria tailored to duodenal pathology rather than applying broad criteria across both stomach and duodenal conditions."},"complexity_factors":["27 distinct causal factors with varying timeframes (ranging from 7 days to 5 years before onset)","Multiple defined terms in Schedule 1 (8 definitions) including technical medical concepts like 'cumulative equivalent dose' and 'systemic mastocytosis'","Nested conditional logic: factors apply differently to 'clinical onset' versus 'clinical worsening' with different drug lists for each scenario","Cross-references to other Statements of Principles for conditions mentioned as factors (section 11)","Specific exclusions in the definition (acute superficial erosions and traumatic perforations excluded)","Dual statutory framework application (VEA and MRCA with different service definitions)","Technical medical terminology throughout (anastomosis, lamina propria, mucosal surface, etc.)"],"plain_english_summary":"This instrument sets the medical test for linking duodenal ulcers and erosions to military service, updating the prior 2015 guidance and identifying specific medical, environmental and psychological factors that can create a reasonable hypothesis of service causation.\n\nIt affects veterans and current/former defence members making claims under the Veterans' Entitlements Act or MRCA and the Repatriation Medical Authority that assesses them — a determination that directly influences entitlement to disability payments and health coverage."},"flash_summary":{"complexity_score":6,"scope_assessment":{"changed":true,"description":"This instrument (commencing 23 July 2024) repeals the earlier Statement of Principles covering both gastric and duodenal ulcers (No. 61 of 2015) (s4) and replaces it with a duodenal‑only Statement (s7). The scope is therefore narrowed to duodenal ulcer and duodenal erosion (and death contributed to by those conditions). It continues to apply to claims under the VEA or MRCA (s5)."},"complexity_factors":["Large number of discrete, medically specific causation factors with precise timing windows (see s9(1)–(27)): infections, treatments, exposures, surgeries, drugs and stressors.","Dose and exposure thresholds that require technical evidence (eg. cumulative equivalent dose ≥10 sieverts within one year — s9(6); 90Y microsphere therapy within one year — s9(7); smoking ≥10 cigarettes/day for 12 months — s9(11)).","Multiple drug-duration rules and overlapping drug lists with different time-frames for onset vs worsening (see s9(12), s9(15)–(17)).","Distinction between clinical onset and clinical worsening and limitation on worsening applying only where condition pre‑existed service (see s10(2)).","Cross-references to other Statements of Principles where factors concern other diseases (s11), creating interdependence between instruments.","Detailed statutory definitions in Schedule 1 (eg. antineoplastic agent, cumulative equivalent dose, critical illness), requiring interpretation of technical terms.","Inclusion of death via contribution to a terminal event and use of medical proximate-cause concepts (s7(5); Schedule 1 terminal event).","Administrative and evidentiary burden on claimants: must establish presence/timing of listed factors, treatments and exposures (see s9 and s5 application to VEA/MRCA claims).","Regulatory change: repeal of prior combined gastric-and-duodenal instrument (s4), narrowing the instrument's subject-matter to duodenal conditions (s7).","Central role of the Repatriation Medical Authority's medical-scientific view as the basis for the instrument (s3, s8), which frames the standard ('reasonable hypothesis') applied to claims."],"plain_english_summary":"**What it does:** This Statement of Principles defines duodenal ulcer and duodenal erosion, and lists specific infections, treatments, exposures, illnesses and behaviours that — if present at or before clinical onset or worsening — raise a reasonable hypothesis the condition (or death from it) is related to a person's military/relevant service. It applies to claims under the Veterans' Entitlements Act and the Military Rehabilitation and Compensation Act and replaces the earlier gastric-and-duodenal instrument."}},"importantCases":[],"_links":{"self":"/api/acts/statement-of-principles-concerning-duodenal-ulcer-and-duodenal-erosion-reasonable-hypothesis-no-49-o","history":"/api/acts/statement-of-principles-concerning-duodenal-ulcer-and-duodenal-erosion-reasonable-hypothesis-no-49-o/history","analysis":"/api/acts/statement-of-principles-concerning-duodenal-ulcer-and-duodenal-erosion-reasonable-hypothesis-no-49-o/analysis","conflicts":"/api/acts/statement-of-principles-concerning-duodenal-ulcer-and-duodenal-erosion-reasonable-hypothesis-no-49-o/conflicts","importantCases":"/api/acts/statement-of-principles-concerning-duodenal-ulcer-and-duodenal-erosion-reasonable-hypothesis-no-49-o/important-cases","documents":"/api/acts/statement-of-principles-concerning-duodenal-ulcer-and-duodenal-erosion-reasonable-hypothesis-no-49-o/documents"}}