Certificate issued under Division 7.5 of the Motor Accident Injuries Act 2017.

1. Revokes the certificate issued by Medical Assessor Garvey dated 17 June 2024 and issues a new certificate as follows:
2. Determines that the following injuries:

(a) Colorectal - Lower gastrointestinal tract dysfunction due to use of medication

(b) Stomach - Upper gastrointestinal tract dysfunction due to use of medication

Are NOT causally related to the motor accident of 6 October 2019.

1. An assessment of the degree of permanent impairment for the above injuries is therefore not required.

Certificate issued under Division 7.5 of the Motor Accident Injuries Act 2017.

The Review Panel combines its assessment of 18 March 2025 and the medical assessment of Medical Assessor Home dated 9 December 2024 and finds:

1. The following injuries caused by the motor accident:
   • Cervical spine
   • Right shoulder
   • Left shoulder
   • Lumbar spine

Give rise to a permanent impairment of 9% and IS NOT GREATER THAN 10%

1. Slobodan Zjalic (the claimant) was involved in a motor accident on 6 October 2019. He was the driver of a car slowing down to turn right when a vehicle collided with the rear of his car. As a result of the motor accident, he says he sustained injuries to his neck, upper back, shoulders, arms, lower back, hips and legs.
2. The claimant attended the emergency department of Wollongong Hospital and was discharged on the same day.
3. The claimant says he developed digestive symptoms, stomach pain and acid reflux about two-and-a-half years after the motor accident. He attributes this to pain relief medications he was taking for his accident-related musculoskeletal injuries.
4. He made a claim for personal injury benefits with GIO, the third-party insurer of the vehicle that he says caused the accident.
5. A medical dispute arose about whether the degree of the claimant's whole person impairment (WPI) is greater than 10% WPI. This is important because if there is a dispute about the degree of a claimant's WPI, damages for non-economic loss[1] cannot be awarded and disputes must be referred to a Medical Assessor/s for determination.
6. On 17 June 2024, Medical Assessor Garvey found the claimant had a WPI of 2% for the injuries to the claimant's gastro-oesophageal reflux and constipation.
7. On 9 December 2024, Medical Assessor Home was referred a further medical assessment and found the claimant had a WPI of 9% for the injuries to the claimant's cervical spine, lumbar spine, right shoulder and left shoulder.[2] The Panel is not aware of any review application lodged against this medical assessment to date.
8. The insurer lodged an application with the Personal Injury Commission (Commission) seeking a review of Medical Assessor Garvey's assessment of the claimant's gastro-oesophageal reflux and constipation.
9. On 21 August 2024, a delegate of the President accepted the application for review and referred the matter to this Review Panel (the Panel) to conduct the Review proceedings.[3]

1. Section 7.21 of the Motor Accident Injuries Act 2017 (MAI Act) provides that the degree of permanent impairment of an injured person is to be assessed in accordance with the Guidelines.
2. The Guidelines were issued pursuant to Division 10.2 of the MAI Act and adopt the American Medical Association's Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4 Guides) (the Guidelines). The Guidelines are definitive with regard to the matters they address by where they are silent on an issue, the AMA 4 Guides should be followed.
3. Permanent impairment is assessed in accordance with Chapter six of the Guidelines.

1. It is necessary for the Panel to consider whether the accident caused or contributed to the claimant's physical injuries. This would include whether the taking of pain relief medication caused or contributed to the claimant's upper and lower gastrointestinal tract dysfunction.
2. The provisions regarding causation of injury are contained in cls 6.5 to 6.7 of the Guidelines.
3. The provisions state:

"6.5 An assessment of the degree of permanent impairment is a medical assessment matter under clause 2(a) of Schedule 2 of the Act. The assessment must determine the degree of permanent impairment of the injured person as a result of the injury caused by the motor accident. A determination as to whether the injured person's impairment is related to the accident in question is therefore implied in all such assessments. Medical assessors must be aware of the relevant provisions of the AMA4 Guides, as well as the common law principles that would be applied by a court (the Commission) in considering such issues.

6.6 Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows:

Causation means that a physical, chemical or biological factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following;

1. the alleged factor could have caused or contributed to the worsening of the impairment, which is a medical determination, and
2. the alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination

This, therefore, involves a medical decision and a non-medical informed judgement.

6.7 There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question 'Would this injury (or impairment) have occurred if not for the accident?' may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes."

1. Further, the provisions of the Civil Liability Act 2002 apply, in particular s 5D and s 5E.

1. Medical Assessor Garvey noted the documented evidence of the claimant complaining of back and bilateral leg pain soon after the motor accident. The claimant was referred to a specialist surgeon who diagnosed an L5 disc protrusion but that the injury could not be operated on.
2. With respect to the claimant's digestive symptoms, stomach pain and acid reflux which occurred about two-and-a-half-years after the accident. The claimant had been taking Panadeine Forte, Nizac, Temazepam 10 mg at night, Benefibre twice daily for constipation and Mirtazapine 45 mg at night for depression. Tramadol was prescribed by his gastroenterologist, Dr Nikola Metrev, but this was stopped because it made his symptoms worse.
3. Dr Metrev examined the claimant's abdomen and chest but there was no endoscopy or colonoscopy, as the claimant could not afford it.
4. The claimant reported current symptoms of a burning stomach, vomiting stomach acid and food contents, burping, constipation, abdominal bloating, gas rumbling in the abdomen, straining at stool, anus pain and occasional blood on the toilet paper.
5. The claimant's current and proposed treatment was to continue with antacid medications and to undergo a gastroscopy and colonoscopy when he could afford it.
6. Medical Assessor Garvey then conducted a physical examination and the findings are recorded at paragraph 12 of his Certificate as follows:

"Inspection: There was no cachexia, pallor of anaemia or jaundice. There was no clubbing of the fingers or liver palms. There were no spider naevi or stigmata of liver disease on the chest. There were no Caput Medusae (distended veins in chest or abdomen). The abdomen was symmetrical and bloated in shape. There were no abdominal masses visible or discolouration. There were no scars, sinuses, fistulas and the umbilicus was normal.

Palpation: There were no enlarged lymph glands palpable in the neck, axilla or groin regions. The thyroid gland was impalpable. The supraclavicular fossae were normal, the external potential hernia orifices were closed, the femoral pulses were palpable and the external genitalia were normal. Light palpation was normal. Moderate palpation of the abdomen was normal in all quadrants. There was no muscular guarding and no rebound tenderness or crossed rebound tenderness. The liver was not palpable, nor was the spleen and the kidneys were not ballotable. There were no abdominal masses palpable.

Testing his conjoint tendons by resisted sit-up was normal on each side. His Carnet's test for abdominal wall pain was negative on each side.

Percussion: The percussion note was resonant and there was no fluid thrill and no shifting dullness.

Auscultation: On auscultation the bowel sounds were normal and there was no aortic bruit and no gastric splash. Rectal inspection (only) was normal and there were no fissures, fistulas or haemorrhoids and no blood. The weight was 133.3 kg and height 191.5 cm (BMI 36.4). Waist circumference was 123 cm. I showed the Claimant the Bristol Stool Chart and he chose numbers 1 Separate hard lumps, like nuts (hard to pass), 3 ("like a sausage but with cracks on its surface") and 6 ("Fluffy pieces with ragged edges, a mushy stool")."

1. Medical Assessor Garvey made the following diagnosis:
   • gastro-oesophageal reflux, and
   • constipation.
2. Medical Assessor' Garvey's causation reasons are:

"The Claimant has developed gastro-oesophageal reflux symptoms only as a result of opiate medicine (but no specific signs) taken to treat his low back pain. 2% WPI is assessed because the Claimant has symptoms only and no physical signs as indicated by the normal physical examination at the Wollongong Hospital on presentation on the day of incident, on the normal physical examination as performed by his treating gastroenterologist and the normal physical examination on today's assessment. 2% WPI is assessed for his symptoms under Clause 6.247 on page 52 of the SIRA guides. The Claimant has developed constipation as a result of medication taken to treat his low back injury. Constipation caused by opiate medicines taken to treat his low back injury is assessed at 0% WPI under Clause 6.248 of the SIRA guides for constipation alone without signs of fissure, fistula or haemorrhoids."

1. Medical Assessor Garvey stated that the impairment was permanent because:

"The upper GI symptoms have been present for at least the last 18 months and have not changed significantly between his initial presentation to the Wollongong Hospital, his treating gastroenterologist and today's physical examination and are unlikely to change by more than 3% in the next 12 months."

1. As alluded to above, the Panel notes that the claimant's musculoskeletal injuries have been the subject of a Further Certificate of Medical Assessor Home dated 9 December 2024. Medical Assessor Home found accident-related injuries to the claimant's cervical spine (5%), lumbar spine (0%), right shoulder (2%) and left shoulder (2%).[5] The total combined permanent impairment from Assessor Home's assessment was 9% WPI.
2. With respect to the gastrointestinal tract dysfunction, the insurer notes that the claimant claims to be suffering from permanent impairment on account of a medication-induced digestive condition secondary to chronic pain as a result of physical injuries sustained in the motor accident.
3. The insurer refers to the Guidelines which advises that occasional, minor dyspepsia, "gas", and belching are within the experience of all normal persons (p. 236).
4. It is submitted that when patients present to a medical practitioner with symptoms consistent with gastroesophageal reflux disease (GORD) or medication induced gastrointestinal motility disorder, it is common practice for them to be advised to stop taking opioids.
5. In this regard, the insurer refers to the report of Dr Ivan Valiozis, gastroenterologist, dated

1 May 2023.[6] Dr Valiozis diagnosed GORD and dyspepsia which was "likely related to constipation with use of Panadeine Forte". In a General Practitioner (GP) note entry dated

1 May 2023, the insurer submits that Dr Valiozis advised that the claimant's conditions resolved with the cessation of medications. 6. Notwithstanding, the insurer argues that this does not prove that the patient's use of opioids was the cause of digestive symptomatology. 7. The insurer further submits that Medical Assessor Garvey's reasoning is deficient in that he has not explained why he assessed the claimant at the maximum possible permanent impairment attributable to a digestive condition of 2% WPI in circumstances where there was:

(a) just one reference to digestive symptoms in the clinical records (consultation dated 25 November 2022);

(b) no direct objective evidence verifying the claimant's reported symptoms to

Dr Greenberg and Medical Assessor Garvey;

(c) no diagnostic testing, for e.g., imaging procedures, fluoroscopy, colonoscopy, or endoscopy examination; and

(d) normal physical examinations from Dr Greenberg, Dr Metrev and Medical Assessor Garvey.

1. The insurer also asserts that Medical Assessor Garvey failed to adequately consider the relevant material and address the insurer's arguments in regard to the same which constitutes a breach of procedural fairness.
2. The insurer's arguments concerned whether the claimant's alleged digestive symptoms are related to the motor accident. The insurer says GORD is a very common condition in the general population and that the claimant's orthopaedic injuries and consequent need for opioid medication were disputed.
3. The insurer further relied on cl 6.244 of the Guidelines which states that "an assessment of impairment to the digestive system must be performed using the methods outlined in Chapter 10 (pages 235-248) of the Guidelines."
4. Chapter 10 of the Guidelines discusses digestive symptoms and confirms that:

"...impairments are evidenced by clinically established or objectively determined deviations from normal in the transport and assimilation of ingested good, the metabolism of nutrition, or the excretion of waste products."

1. Again, the insurer refers to the need for objective testing measures to verify the claimant's subjective reporting of impairment to the digestive system.

1. The claimant says Medical Assessor Garvey provided adequate reasons for the assessment of 2% WPI for the upper digestive tract. The reasons include the Medical Assessor's review of the documentation, his own physical examination findings and the exercise of his discretion when assessing 2% when having regard to the 0-2% range in the assessment criteria under the Guidelines.

1. On 23 August 2024, the Panel issued a direction to the parties requiring indexed and paginated bundles of the information they relied upon. Both parties duly responded with the insurer's bundle comprising of pages 1-479 and the claimant's 1-129.
2. The Panel has read the documentation however will not refer to and summarise every document that are contained in the bundles. The Panel will only refer to the material that are relevant to the issues in dispute and matters to be determined with respect to the review of Medical Assessor Garvey's WPI assessment.

1. Discharge referral note Wollongong Hospital dated 6 October 2019 -

"Able to walk unaided but had some upper thoracic and lower lumbar pain and tenderness. No other significant injuries. X-ray lumbar spine. The lateral view of the lumbar spine seems to show a mild compression fracture of L5 vertebral body with loss of normal lumbar lordosis." 2. Dr Anthony Greenberg, Gastrointestinal Surgeon, report dated 30 August 2023 - "Obtained a history that the claimant was taking Panadeine Forte to help manage his chronic pain from the musculoskeletal injuries sustained in the motor accident. However, this was reported to cause the claimant upper and lower gastrointestinal symptoms. Dr Greenberg noted that Panadeine Forte is classified as an opioid and recognised to alter gastrointestinal motility. He diagnosed the claimant with accident-related analgesic gastropathy, gastro-oesophageal reflux disease (GORD) and a medication induced gastrointestinal motility disorder. Dr Greenberg assessed the claimant's permanent impairment under the AMA 4 Guides as: Upper GI - 3% WPI and Lower GI - 3% WPI which was combined to give 6% WPI." 3. Wollongong Medical Centre - Records from Wollongong Medical Centre spanning the period 1 August 2022 to 20 February 2025 were received and reviewed by the Panel. The Panel noted regular prescriptions for Mirtazipine, Temazepam and Panadeine Forte on a three weekly to two monthly basis. There was also nizatidine (Nizac) prescriptions from 5 August 2023, then

11 May 2024 and thereafter at between monthly and three-monthly intervals with the last prescription on 20 February 2025. The latter is prescribed to treat reflux symptoms and does not appear until almost four years after the accident. Reflux symptoms (heartburn) and constipation are first mentioned on 25 November 2022, three years after the accident; noting the claimant had first been prescribed Panadeine forte for musculoskeletal pain on or around 16 November 2019. The Panel did not find any reference to the ingestion or prescription of anti-inflammatory medication in the GP records from the date of accident to 20 February 2025 Dr Mitrev, gastroenterologist did refer to the ingestion of Nurofen (anti-inflammatory) in his report of 1 May 2023, however, on close questioning by the Panel Medical Assessors, the claimant replied he had not taken anti-inflammatories on any regular or prolonged basis, even over-the-counter supplies and the GP record showed no evidence that

anti-inflammatories were recommended or prescribed by his treating doctor. 4. Claimant statement dated 22 February 2024 - Prior to the motor accident, the claimant was in good health, had no problems with his digestion and was not using any pain killing medication.

(a) Panadeine Forte one to two tablets per day, three times on average;

(b) Mirtazapine 45 mg, one at night;

(c) Temazepam 10mg, one at night;

(d) Tramadol 50mg (used temporarily, did not relieve my pain);

(e) Nizac (a medication for my gastrointestinal symptoms (300mg, once per day);

(f) Benefiber one to two per day for constipation, and

(g) Duloxetine (recently prescribed by psychiatrist).

The claimant says using the medications above at (a) through (c), he developed digestive symptoms as identified by Dr Greenberg. These symptoms became worse over time. The claimant did not seek medical treatment until it reached a point where the symptoms became pending (sic?).

Since the accident, the claimant says he had the following symptoms:

(a) burning sensation in chest and throat;

(b) nausea;

(c) vomiting;

(d) constipation;

(e) bowels open only once every three to four days, and

(f) occasional rectal bleeding and selling.

1. Dr Nikola Mitrev, Gastoenterologist, report dated 1 May 2023 - Opined that the claimant was predominantly getting constipation from the Panadeine Forte and probably some dyspepsia from the Nurofen. Gave Benefiber to treat any underlying constipation. Found the claimant's GORD and dyspepsia to have "...resolved on cessation of all medications in the last few weeks".

1. The Panel noted that the issues to be decided concerned the claimant's use of medication and whether this caused the claimant's upper and lower gastrointestinal tract dysfunction. There was no evidence from Medical Assessor Garvey, Dr Greenberg and Dr Mitrev of abnormal examination findings. The Panel therefore determined that it was important to hear from the claimant and obtain an up-to-date history of his symptoms and use of the various medications. A physical examination was not required and would not add to the Panel's knowledge of the issues to be decided.
2. The assessment was therefore conducted via Microsoft Teams video link and below is the Panel's report:

Mr Zjalic attended an MS Teams videolink assessment unaccompanied. He was assessed by Medical Assessor Gibson and Medical Assessor Oates on behalf of the PIC Medical Review Panel on 7/02/2025 as arranged.

Pre-accident medical history and relevant personal details

He stated that he had had no previous injuries and no previous surgery. He was not on any regular medications. His weight was steady at about 100kg. He had no history of oesophageal reflux or constipation. He was on prescribed medication and specifically was not using over-the-counter medications for reflux, such as Gaviscon or Mylanta.

His current weight is 123kg and he said when he was assessed by Assessor Garvey, he was 133.3kg with height 189cm. He says he has lost weight since that time because of being told to curtail his eating. His appetite remains normal.

Mr Zjalic said that on 6/10/2019, he was driving a Nissan Pulsar sedan with no passengers on the way to visit his father in Wollongong Hospital. He was slowing down to turn right into the driveway of a service station, when he was rear-ended by a following car. He did not hit anything in front.

His car was written off because the repairs to the rear end were going to cost more than it was worth ($2,500).

History of symptoms and treatment following the motor accident

His car was driveable after the accident. He continued to the Wollongong Hospital and then went to their Emergency Department complaining of neck, thoracic and lumbar spine pain. He had imaging done and was given painkillers.

He subsequently saw his GP, Dr Bukoje, Wollongong Medical Centre on 11/10/2019 complaining of lower back pain radiating to both legs as far as the knees, with pins and needles and numbness over the back and outer sides of both thighs, along with neck pain and stiffness, with pain radiating into the right shoulder and right arm, down to the right 4th and 5th fingers, with pins and needles in the right shoulder, and pain in both shoulders, right greater than left, as well as anxiety.

He was diagnosed with whiplash injury to the neck, right and left shoulder pain, and lower back ?disc prolapse, and prescribed analgesia as required.

He was sent for a CT scan of lumbar spine and plain x-ray of right and left shoulders, and right and left hips.

At review on 16/10/2019, CT scan showed a generalised L5/S1 disc bulge. He was referred to Dr El-Khawaja, neurosurgeon, and prescribed Panadeine Forte 1-2 tablets every six hours with meals as required.

He saw Dr El-Khawaja who arranged an MRI scan of the lumbar spine. The doctor told him no surgery was indicated, nor did he require spinal injections.

He continued treatment with his GP, records from whom are available to the Panel up until 18/10/2023. The Panel notes he was prescribed Nizac (Nizatidine) for reflux symptoms on 5/08/2023.

Mr Zjalic also told the Panel that as well as Panadeine Forte, he would take Panadol for headaches now and then, and was prescribed mirtazapine to manage psychological symptoms of stress, taking 45mg at night, and also temazepam 10mg at night to help him sleep. He says these medications of Panadeine Forte, mirtazapine and temazepam commenced shortly after the accident and he continued to take them.

He was referred to a psychiatrist regarding his emotional state and was prescribed duloxetine 60mg for a period of time, but could not afford to continue seeing the psychiatrist, who was the only doctor able to prescribe this medication, so he continued with mirtazapine.

Although there is reference in the medical documents to his taking Nurofen (ibuprofen - an anti-inflammatory) at some stage, the claimant informed the Panel that he did not take anti-inflammatory medication on any regular or continuing basis, as far as he can recall.

Mr Zjalic said that two years after the accident, he developed gastrointestinal symptoms of oesophageal reflux with lower retrosternal chest pain, abdominal bloating and nausea, and symptoms of constipation and rectal pain and occasional bleeding on the toilet paper after defecation. He continued to take the analgesic medication of Panadeine Forte because of continuing and worsening symptoms of neck and back pain over time, along with attending a physiotherapist periodically. He had an initial course of physiotherapy funded by the insurer, but thereafter has accessed physiotherapy under Medicare and also attended a masseur, which is self-funded, approximately once a month.

The Panel notes the first reference to gastrointestinal symptoms was recorded in a visit to his GP on 25/11/2022, where he presented with persistent pain in the stomach, heartburn, bloating, constipation and intermittent diarrhoea related to taking regular painkilling medication.

A referral letter to Dr Valiozis, gastroenterologist, Wollongong was written on that date, so that the symptoms could be assessed.

The Panel notes that a prescription for Panadeine Forte, Temazepam and Mirtazapine were issued on 25/11/2022.

The records show Mr Zjalic attended a different gastroenterologist, Dr Nikola Mitrev, Wollongong on 1/05/2023. Dr Mitrev noted that Mr Zjalic had stopped his mirtazapine, Panadeine Forte and temazepam a few weeks before the consultation and all his abdominal symptoms, which consisted of GORD and dyspepsia and constipation, had resolved and that he denied any PR bleeding.

On examination his abdomen was soft and non-tender. Dr Mitrev believed that the constipation was the result of Panadeine Forte and there was probably some dyspepsia (upper gastrointestinal symptoms) from Nurofen, which he reported having taken. The doctor suggested if he had any recurrent symptoms, he would suggest a urea breath test and potentially Helicobacter pylori eradication therapy. He issued him with a script for nizatidine (Nizac) which he was to take should he get the reflux again, and also Benefiber to treat any underlying constipation. He also gave him a short course of tramadol for his continuing musculoskeletal pain to see whether this brings on the constipation. He also recommended a pain specialist referral ultimately. This was in an effort to find a better regimen for his pain medication that will not impact the bowel as much.

Mr Zjalic told the Panel Medical Assessors that his GP had told him to eat less and avoid foods which triggered the reflux, and to eat a few hours before going to bed, but did not recommend any over-the-counter medications for reflux. He said he did not know which foods triggered reflux.

The tramadol prescribed by Dr Mitrev did increase his stomach pain and he believes the acid reflux, so he ceased this after a short time and returned to taking regular Panadeine Forte, but the symptoms affecting the upper and lower digestive system got worse again over time.

The Panel noted a further GP record indicating that Mr Zjalic had stopped Panadeine Forte and mirtazapine and temazepam a few weeks before, and symptoms had resolved. Mr Zjalic then clarified that he would take breaks from the medications when the symptoms affecting the upper and lower digestive tract became bad, but then his back pain would worsen and cause increasing incapacity, so that he would have to resume these medications, including Panadeine Forte, and then the symptoms affecting the digestive tract would return again within the same day. This would consist of burning in the chest and up into the throat, and then vomiting acid liquid.

Mr Zjalic told the Panel that he has continued to be prescribed these medications, along with Nizac which he takes daily and Benefiber, two per day, Panadeine Forte 1-2 tablets up to three times a day, mirtazapine 45mg at night, and temazepam 10mg at night.

He still has reflux symptoms and they are getting worse. He has constipation with a bowel motion only every 3-4 days, and pain and swelling around the anus with blood on the toilet paper noted at times. He gets bloating and cramps in the abdomen.

Despite these symptoms, he says his appetite is good and his weight had continued to rise until he was told to reduce it, so he has been consciously trying to cut down on the amount he eats and has lost some weight as a result.

He says he gets a script for his medications every two or three weeks from the GP.

With regards to social history, he has a defacto partner but they live apart for financial reasons. He lives with his mother and was doing so at the time of the accident and this situation continues. He and his partner have a daughter who lives with the partner. His mother does the housework, as he does not engage in any household chores. His partner will help out if she comes over to their place.

He has not worked since before the accident, at which time he was a truck driver. In earlier times he did carpentry. He has received Centrelink Newstart benefits but passed onto a DSP (disability support pension) approximately 12 months ago.

Before the accident, he played team soccer until the age of 18 and thereafter social soccer and also did swimming. Since the accident he is no longer able to play any sports because of his back pain, and tiredness because of sleepless nights when acid reflux wakes him up and he has to get up to try and vomit the acid liquid into the toilet.

He was born in Serbia and came to Australia at the age of 11 and completed his education to Year 12."

1. The review of the medical assessment is not limited to a review of only that aspect of the assessment that is alleged to be incorrect and is to be by way of a new assessment of all the matters with which the medical assessment is concerned.[7]
2. The Panel may confirm the certificate of assessment or revoke that certificate and issue a new certificate as to the matters concerned.[8]
3. A Panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application.[9]
4. The Panel refers to the above re-examination report of Medical Assessors Oates and Gibson and adopts the findings in their entirety. The Panel reconvened on 7 February 2025 and discussed the re-examination report findings before collectively making the below determinations.

1. The diagnosis is upper gastrointestinal tract dysfunction (GORD or gastroesophageal reflux disorder) and lower gastrointestinal tract dysfunction - constipation.
2. The diagnosis is made on the basis of symptoms reported by the claimant and material in the file of evidence.
3. The Panel notes there has been no gastroenterological investigations, such as urea breath test for Helicobacter pylori infection, which can cause reflux and stomach upset, nor endoscopy to obtain visual evidence of any lesion in the oesophagus or stomach, nor colonoscopy to obtain any visual evidence of lesions in the lower digestive tract.
4. The claimant stated that he cannot afford to have these investigations.
5. The Panel was puzzled by the lack of referral for investigations through the public hospital system because the claimant has no health cover, in view of the claimed duration and severity of his symptoms.

1. The Medical Assessors noted the claimant's history of the onset of gastrointestinal symptoms some two years after the accident, and note the first reference in the contemporaneous medical records were in November 2022, which is more than three years after the accident. Because of the lack of a temporal nexus between the commencement of the imputed medication, namely Panadeine Forte (opioid analgesic) and the onset of symptoms, the Medical Assessors do not accept there is a causal link between medication taken for musculoskeletal injuries caused by the accident and the upper and lower digestive complaints.
2. If Panadeine Forte was the cause of gastrointestinal hypomotility disorder, manifesting as abdominal bloating and constipation, the Panel Medical Assessors would have reasonably expected symptoms to occur much earlier than two years plus after the commencement of such medication, which the claimant indicated was taken on a regular daily basis. In the experience of the Panel Medical Assessors, the constipating effect of opioids will occur within a few days to weeks of commencement of regular dosage, and in individuals more sensitive to this effect, severe constipation can occur after the very first dose.
3. While the Panel had records from Wollongong Medical Centre spanning the period

1 August 2022 to mid-2023, the Panel felt it was prudent to call for updated records to confirm that the claimant continued to be prescribed Panadeine Forte on a regular basis. The updated records showed that Panadeine Forte was prescribed by the claimant's GP,

Dr Vukoje every month or two until the end of the records in February 2025. This was consistent with the history Mr Zjalic gave to the Medical Assessors at the panel

re-examination. 4. If the treating doctor felt that Panadeine Forte was causing the digestive tract symptoms, the Panel Medical Assessors would naturally expect this medication to have been replaced by either a non-opioid based analgesic, or else trial Targin which contains naloxone to reduce the side-effect of constipation. The evidence further supports the Panel's view that the Panadeine Forte did not cause the claimant's upper and lower digestive complaints. 5. Furthermore, the Medical Assessors cannot find a causal link between the medication taken, namely opioids, mirtazapine, temazepam, and the condition of GORD. GORD is caused primarily by aspirin or other anti-inflammatory medication taken on a regular basis and this has not been the case here. Although there is occasional mention of ingestion of Nurofen (ibuprofen, an anti-inflammatory), the claimant told the Medical Assessors that he had rarely taken Nurofen and had not taken this for a very long time, if ever. 6. Using their medical expertise, the Panel Medical Assessors would have expected that were a medication to be implicated in causation of GORD symptoms, presumably through some casual or short-term use of an anti-inflammatory, that the onset of symptoms would have occurred within weeks to months of commencing such use, but that is not the history which is present in this matter. 7. The Panel Medical Assessors note the opinion of Dr Greenberg, who relates the constipation to the ingestion of opioids, but does not comment on the long interval between the commencement of ingestion of this drug and the onset of the constipation symptoms, and also in noting the possibility that opioids through causing gastrointestinal hypomobility disorder could lead to delayed gastric emptying and aggravate the effects of an oesophageal reflux condition, but again did not make reference to the long interval between commencement of medication and onset of symptoms. 8. The Panel Medical Assessors note that Dr Greenberg's opinion appears to imply that opioids could have worsened the effects of an existing reflux disorder, by delaying gastric emptying through their slowing of peristaltic contractions of the digestive tract (hypomobility), which is in keeping with accepted medical knowledge that anti-inflammatories are the primary cause of reflux symptoms, not opioids. 9. This refers to the case where medications are implicated in aetiology of gastrointestinal disorders. 10. The Panel therefore concluded that the claimant's use of medication to help control the pain associated from his accident-related physical injuries could not have, and, did not cause the claimant's upper and lower gastrointestinal tract dysfunction. 11. While acknowledging and accepting that the claimant did not have such symptoms before the motor accident, the Panel could not accept that the opioid medication caused the claimant's gastrointestinal symptoms. This is because the first symptoms did not present until over two- years after the motor accident in circumstances where the claimant was regularly taking the prescribed opioid medication and which did not, or rarely, included anti-inflammatory medication.

1. The following injuries were NOT caused by the motor accident:
   • Gastroesophageal reflux
   • Constipation

1. Because the Medical Assessors found that the referred injuries were not causally related to the accident, there is therefore no permanent impairment from these conditions which can be related to the motor accident.
2. Furthermore, the Panel note that Cl 6.247 of the Guidelines are not satisfied because this clause specifically refers to upper digestive tract disease caused by the commencement and ongoing use of anti-inflammatory medications.
3. As mentioned above, the Panel obtained no history and there is no evidence to suggest any ongoing use of anti-inflammatory medications by the claimant.
4. In relation to the claimant's constipation, the Panel notes that had this injury been accepted as being causally related to the motor accident, it would not result in any permanent impairment because under cl 6.248 of the Guidelines, constipation alone in the absence of proven colonic or rectal disease results in an impairment of 0% WPI.

1. The Panel therefore concluded that the claimant's use of opioid medication that he was prescribed to help control the pain associated from his accident-related physical injuries could not have, and, did not cause the claimant's upper gastrointestinal tract dysfunction manifesting as reflux. Opioids could have caused lower gastrointestinal tract dysfunction, because digestive tract hypomotility resulting in symptoms of constipation, abdominal discomfort and nausea is a recognised side-effect of this medication however in this claimant's case they did not cause this dysfunction because of the very prolonged period of regular use of this medication before the reported onset of any symptoms. In the clinical experience of the Panel Medical Assessors, were opioid medication to be the cause, symptoms would have manifested within 1-2 days to a few weeks of the commencement of the medication.
2. The Panel was not satisfied that the injuries were causally related to the motor accident. The Panel therefore revokes the certificate of Medical Assessor Garvey and issues a new certificate in accordance with the Panel's above findings and reasons for assessment.
3. The Panel also issues a combined certificate combining its assessment with that of Medical Assessor Home.
4. Both certificates are located at the front page of this decision.

[2] Medical Assessor Home's original medical assessment certificate dated 21 March 2022 assessed 10% WPI for the same injuries.

[4] The insurer's further submissions [RP1], review submissions [RP3], submissions on gastrointestinal dysfunction [RP5] and submissions seeking further medical assessment [RP19] are summarised together.

[5] Parentheses value denote WPI percentage assessed by Medical Assessor Home.

[6] For clarity, this report was actually produced by Dr Mitrev, not Dr Valiozis.

[9] Rule 128 of the Personal Injury Commission Rules 2021.