Replacement Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017

1. The panel revokes the certificate of Medical Assessor James Cowlishaw dated

17 December 2024. 2. The following injury was not caused by the motor accident:

(a) Intestine - Gastro-oesophageal reflux disease, analgesic gastropathy, and

(b) medication-induced gastroinstinal motility disorder.

1. The claimant is a 62-year-old man who was injured in a motor vehicle accident on

25 October 2022. Following the accident, the claimant lodged an application for personal injury benefits and thereafter it was determined that the claimant had sustained

non-threshold injuries. 2. The claimant sought a concession from the insurer that his injuries exceeded 10% whole person impairment (WPI). Following a review, the insurer declined to make this concession and consequently, the claimant lodged an application for assessment of WPI. 3. The claimant was examined by Medical Assessor James Cowlishaw on 3 December 2024. In a certificate dated 17 December 2024, he determined that the injuries caused by the motor accident gave rise to an impairment of 5%. That is intestine - Gastro- oesophageal reflux disease, analgesic gastropathy and medication induced gastrointestinal motility disorder. 4. The insurer sought a review of this determination, and in a certificate dated 2 April 2025 President's Delegate Ratula Gupta determined that there is a reasonable cause to suspect that the medical assessment is incorrect in a material respect. The matter has now been referred to this Medical Panel. 5. Directions were issued to the parties to upload all material which was before Medical Assessor Cowlishaw, and this has now been done. 6. The Panel convened on 23 June 2025 and determined that it was appropriate to re-examine the claimant by audiovisual link as there is a need to clarify the claimant's history. Thus, arrangements were made for the claimant to be seen over Microsoft Teams by Medical Assessor Sethi on 4 August 2025.

1. At the beginning of the interview, I explained the purpose of an independent medico-legal examination. I indicated that I was not a treating doctor and was unable to provide any advice. I reviewed available medical records. Azzam Elmir attended the interview with an interpreter. The interview was conducted by Microsoft Teams.
2. This assessment was conducted via video conference with verbal consent obtained from the claimant to have this assessment. The claimant has been provided with the telehealth consent form and confirmed that they have read it and have had the opportunity to ask questions. The claimant was located in New South Wales, and I was located elsewhere in New South Wales
3. I am satisfied that my and Azzam Elmir's physical environment and the technological equipment used was adequate for undertaking this assessment effectively.
4. I do not require any additional information, tests or face to face follow up in order to deliver my opinion.
5. I was satisfied that I was able to assess Azzam Elmir to an adequate standard to which my clinical opinion can be relied upon.
6. I reviewed available documentation in this case.

1. On 25 October2022, Mr Elmir was involved in a motor vehicle accident whereby he was in a car that was stationary at a traffic light and was struck from behind. He was wearing a seatbelt, and the airbags did not deploy. The car was driveable afterwards and was repaired. There was no direct impact to his chest or abdomen. He was able to exit the vehicle on his own without any assistance and did not immediately attend a hospital or seek medical attention.
2. Mr Elmir subsequently developed chronic pain in his neck, shoulders, elbow, pelvis and left knee for which analgesia with Panadeine Forte, Lyrica, Gabapentin, Mobic and Nurofen were prescribed. He underwent hydrotherapy and physiotherapy.
3. After starting analgesic medications, Mr Elmir began experiencing a burning sensation in the epigastrium radiating up the chest. This was associated with mild nausea and a feeling of acidity in the throat. Nexium was prescribed to partial effect. There was bloating, excess gas and a feeling of abdominal fullness. He has not had gastroscopy before.
4. His bowel habits began tending towards constipation where he passed small hard motions every two days.
5. Mr Elmir reports that in June 2021, he had experienced epigastric pain described as a burning sensation which was treated with Pariet to good effect. Breath test showed that he was positive for helicobacter pylori for which he was prescribed a one-week course of antibiotic therapy.
6. He blames the analgesic medications that he was prescribed to treat chronic pain arising from the motor vehicle accident for causing him to experience gastrointestinal symptoms. The dose of analgesic medications was substantially reduced in 2024, and his gastrointestinal symptoms have not improved since.
7. Currently, his symptoms of epigastric burning sensation, bloating, excess gas and fullness are persisting.
8. He smokes 15 cigarettes daily and does not consume alcohol.

1. Mr Elmir was born in Lebanon, attended school till Year 12, started but did not complete a university course, worked in carpentry, upholstery and did formwork. He migrated to Australia in 2001, worked as a carpenter, was not working at the time of the injury or currently. He is receiving a disability support pension.

1. Mr Elmir is married with five children, lives in a rented house and reports that he struggles to perform several activities of daily living including cleaning, cooking, driving, gardening, laundry and shopping.

(a) Mobic 2 tablets daily;

(b) Nexium 20mg daily;

(c) Panadeine forte 2 tablets daily;

(d) Nurofen as needed (once every few days), and

(e) Mirtazapine 120mg daily.

1. Mr Elmir is 170 cm tall and weighs 78 kg. This equates to a body mass index (BMI) of 27.2 (normal range 20 - 25) and classifies as overweight.
2. As this was a Microsoft Teams consultation, physical examination could not be performed.

1. Mr Elmir is a 62-year-old gentleman who was involved in a motor vehicle accident after which he developed chronic pain requiring analgesia with Panadeine Forte, Lyrica, Gabapentin, Mobic and Nurofen. He subsequently experienced epigastric burning sensation, bloating, excess gas and fullness which he blames on the analgesic medications that he was prescribed.
2. The Panel does not agree with this. In the Panel's opinion, the claimant has developed gastro-oesophageal reflux disease (GORD) and irritable bowel syndrome (IBS) entirely of his own accord and his employment, work injury and the analgesic medications that he was prescribed did not play any causative role whatsoever. They have occurred regardless, and the Panel's reasoning is below.
3. The claimant's original work injury did not directly involve the gastrointestinal tract.
4. The motor vehicle accident involved only very minor trauma, noting that he did not have any direct injury to his abdomen nor seek medical attention immediately afterwards.
5. His description of epigastric burning sensation is strongly suggestive of GORD. This is a very common condition affecting around 15% to 20% of the general population and is caused by laxity of the gastro-oesophageal sphincter valve. This is accepted widespread medical and scientific opinion.
6. Mr Elmir is overweight with a BMI of 27.2. Raised BMI is well described in the medical and scientific literature to worsen GORD.
7. He smokes 15 cigarettes daily. Smoking is well described in the medical and scientific literature to worse GORD.
8. His description of bloating, excess gas and fullness is strongly suggestive of IBS. This is a very common condition affecting around 15% to 20% of the general population and is caused by visceral hypersensitivity of the gastrointestinal tract.
9. Mr Elmir's smoking and raised BMI have both contributed to his IBS. These are well described in the medical and scientific literature to worsen IBS.
10. He has a past history of GORD given that he had experienced similar symptoms prior for which he was prescribed Pariet.
11. In view of his past medical history of similar symptoms, raised BMI and smoking, GORD was a constitutional condition for him and was entirely unrelated to and completely independent of the motor vehicle accident.
12. The analgesic medications that he was prescribed do not reasonably account for his gastrointestinal symptoms. I note that the dose has been substantially reduced yet his symptoms have not improved since. Currently, he is taking analgesic medications at a very low dose. I note that he takes only two tablets of Mobic and two tablets of Panadeine Forte which does not explain his symptoms.
13. The Panel agrees that Mr Elmir has gastro-oesophageal reflux disease, but this is independent of the motor vehicle accident.
14. The Panel does not agree with the diagnosis of analgesic gastropathy noting that he has not had a gastroscopy before. This diagnosis can only be made on gastroscopy hence the diagnosis of analgesic gastropathy is invalid. While Nurofen could potentially have caused him to develop gastric damage, this should have been healed by taking Nexium.
15. The Panel does not agree with the assessment of medication induced gastrointestinal motility disorder. Mr Elmir's symptoms are far more suggestive of IBS rather than intestinal motility disorder.
16. Given that his gastrointestinal symptoms have not arisen from the motor vehicle accident, no rating for WPI is applicable.

1. The Panel does not consider that the motor accident has caused the claimant to suffer any gastro-intestinal injuries.