vRECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2013-01703
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20140522
SEPARATION DATE:  20040423

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve TSgt/E-6 (1T171/Air Crew Life Support Craftsman) medically separated for ulcerative colitis (UC) and proctitis.  The ulcerative colitis/proctitis could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS) or satisfy physical fitness standards.  He was issued a permanent P4 profile and referred for a Medical Evaluation Board (MEB).  “Ulcerative colitis and proctitis” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The Informal PEB (IPEB) adjudicated “ulcerative colitis and proctitis” as unfitting, rated 10%, with application of the VA Schedule for Rating Disabilities (VASRD).  The PEB also adjudicated hyperlipidemia as a Category III condition, one that is not separately unfitting and not compensable or ratable.  The CI appealed to the Formal PEB (FPEB), which affirmed the IPEB findings and rating.  The CI was then medically separated.

CI CONTENTION:  The CI writes: “Ulcerative colitis—Air Force determined a 10% rating and a month later the VA increased it to a 60% rating for service connected issues.  Ulcerative colitis continues to worsen-symptoms disturb daily life and sleep cycles.  Another lower GE scheduled 10 Oct 2013 to determine progression.  Steriods issues multiple times to suppress flare ups and current meds not working”.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting UC and proctitis condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  The sleep apnea which was service-connected by the VA, making up the 60% VA rating, was not identified by the PEB and is not within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the Military Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws.  The Board considers DVA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence.  Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

RATING COMPARISON:

Service FPEB – Dated 20040226	VA - (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Ulcerative Colitis and Proctitis	7323	10%	Ulcerative Colitis/Proctitis	7399-7323	10%	STR	
Other x 0 (Not in Scope) 	Other x 3	STR	
Rating:  10%	Combined Rating :  60%	
Derived from VA Rating Decision (VARD) dated 20040809 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY: 

Ulcerative Colitis and Proctitis.  According to the MEB narrative summary (NARSUM), the CI described experiencing periodic symptoms of UC (chronic bowel disease characterized by inflammation of the colonic mucosa)/ulcerative proctitis (inflammation of the colonic mucosa limited to the rectum) beginning in 1996 including diarrhea, blood in the stool and abdominal cramping.  Primary service treatment records from April 1995 through July 1999 when the CI separated from active duty, disclosed a clinic encounter in July 1996 for an episode of diarrhea.  The treatment records were otherwise silent with regard to complaints of diarrhea.  A clinic encounter on 24 December 1997 for blood on the toilet paper without abdominal pain or diarrhea concluded with a diagnosis of hemorrhoids.  Laboratory results (blood count) from February 2000 were normal without indication of chronic inflammation or blood loss/anemia.  The next treatment record entry with gastrointestinal complaints was 4 November 2001 when the CI complained of frequent stool for 2 days duration.  The examiner recorded a report that there were no prior medical problems.  Laboratory testing was normal without indication of chronic inflammation.  A radiographic barium study of the small intestine, dated 28 November 2001, was normal.  A colonoscopy performed by a gastroenterologist on 4 December 2001 disclosed inflammation near the appendix and in the rectum.  The diagnosis of UC was made based upon colonoscopy biopsy findings and treatment was initiated.  At the time of a clinic follow-up on 26 December 2001, the examiner recorded that the CI reported the problem had resolved.  The CI presented for care on 28 June 2002 for stomach cramps and sweats during a 3-day trip to the Caribbean.  At a 7 September 2002 periodic health examination, the CI checked “No” in response to the question regarding whether he had a history or treatment for inflammatory bowel disease in the preceding year.  On 22 November 2002, the CI was reactivated to active duty and deployed to Kuwait on 3 December 2002.  According to the MEB NARSUM, the CI experienced the recurrence of symptoms of UC immediately with deployment.  At the deployed clinic encounter on 30 December 2002, when the CI complained of episodes of testicular pain, the examiner recorded, “denies any other problems.”  In the deployed clinic encounters on 2 January 2003 and 5 January 2003, there was no complaint or history of bowel problems recorded.  The Post-Deployment Health Assessment on 24 January 2003 records only the testicular problem and makes no reference to gastrointestinal problems while deployed.  The next clinic encounter recording gastrointestinal complaints is a telephone nurse consult on 5 February 2003.  The CI complained of blood in the stool four times per week with inflammation of the colonic mucosa six bowel movements per day without cramping.  The CI was seen the next day in the clinic and the encounter recorded “states he has seen blood in stools as of late.”  The history of ulcerative proctitis was noted and he was referred to gastroenterology.  At the gastroenterology appointment on 10 February 2003, the CI reported experiencing seven to eight bowel movements per day with occasional cramping.  The gastroenterologist noted, “He has really not been taking the Rowasa suppositories recently.”  On examination, the abdomen was non-tender and the stool negative for blood (and occult blood) on rectal examination.  The gastroenterologist advised resuming use of the medicated suppositories and started the CI on an oral medication for the condition.  Laboratory testing performed on 10 February 2003 was normal showing no anemia or indication of chronic inflammation.  A family practice appointment on 17 March 2003, noted he performed the same job as a civilian government worker as his military job, but initiated MEB and issued a profile for no deployment pending outcome of the MEB and PEB.  At a follow-up appointment on 17 March 2003, the gastroenterologist recorded reports of seven to eight bowel movements per day and occasional cramps.  There was no blood in the stool, no weight loss and no loss of appetite.  He reported he was not able to hold the suppositories in his rectum.  On examination, the abdomen was non-tender and the rectal examination negative for blood (including occult blood).  The dose of the oral medication was increased and he was encouraged to continue to use the suppositories.  The next family practice clinic encounter on 3 September 2003 noted his last appointment with gastroenterology was 4 months prior.  The examiner noted the MEB had not yet been accomplished.  The CI reported that every time he deployed his UC would flare up.  The provider referred the CI back to his gastroenterologist.  The gastroenterologist, by memorandum dated 17 September 2003, stated the CI had not completely responded to medications and still experienced six to seven bowel movements per day and needed to be near a bathroom at very irregular times.  The gastroenterologist stated that any sort of military mobilization or increased stress “may make the situation worse.”  The 30 September 2003 family practice clinic appointment noted laboratory testing was negative for systemic inflammation (normal erythrocyte sedimentation rate).  A clinic entry on 28 October 2003, recorded the CI request for medication for motion sickness for scuba diving classes.  The commander’s statement on 5 November 2003, noted that despite his symptoms, his duty performance had never lagged but he could not deploy.  He worked full duty days in his AFS and rarely missed work due to appointments or treatment.  The 5 December 2003 IPEB found the CI unfit for UC and proctitis and recommended discharge with severance pay with a disability rating of 10% IAW DOD and VASRD guideline.  On 12 December 2003, the CI did not agree with the findings and recommendations of the IPEB and demanded a formal hearing of the case.  A 17 January 2004 barium enema with air contrast study of the colon showed diverticulosis.  The barium study was otherwise normal suggesting remission of the UC or proctitis (no mucosal lining irregularities, ulcers, or fine serrations characteristic of ulcerative colitis).  The CI sought a second gastroenterology opinion in February 2004.  On 19 February 2004, the second gastroenterologist’s memorandum, recorded reports of recurrent exacerbations and flares of UC since it was diagnosed 2 years before, associated with more than 10 to 15 bowel movements per day, abdominal pain and cramping, and intermittent rectal bleeding.  The gastroenterologist noted he needed access to a bathroom at frequent and unexpected times.  An updated commander’s statement, by a different officer on 21 February 2004, noted frequently and lengthy trips to the bathroom causing a decline in duty performance.  The commander noted a decline in duty performance over the past several months.  An addendum to the MEB by a family practice physician assistant on 24 February 2004, noted a report of over 10 bowel movements per day hindering job performance; “maximum of four to six hours of productive work per day, often much less.”  The 26 February 2004 FPEB found the CI unfit for UC and proctitis and recommended discharge with severance pay with a compensable percentage of 10%.  At a 7 April 2004 clinic visit for a civil service medical examination, the CI reported he continued to have slight problems with blood and mucous in the stools.  No work restrictions were indicated.  At the 19 July 2004 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI complained of frequent bowel movements, up to eight daily, with periodic blood and mucus.  The CI reported chronic use of rectal and oral forms of the same anti-inflammatory drug for treatment and prophylaxis of his ulcerative colitis and ulcerative proctitis.  He reported he remained gainfully employed in his government job but was not on flying status.  On physical examination, the CI’s weight remained stable without loss.  The abdominal examination was normal, with normal bowel sounds, and non-tender.  The CI declined rectal examination.  The VA C&P examiner noted the January 2004 barium enema which showed no evidence of active or inactive ulcerative colitis, suggesting the condition to be in good remission.

The Board directs attention to its rating recommendation based on the above evidence.  The FPEB rated the UC (coded 7323) 10%, citing it did not rise to the level of the 30% rating which required moderately severe with frequent exacerbations.  The VA similarly rated the UC condition (coded 7323) 10% resolving reasonable doubt in the favor of the CI.  The VA noted the barium study suggesting remission, but with symptoms and continued treatment.  The Board undertook to ascertain the severity of the ulcerative colitis/proctitis condition.  All members agreed the condition was not pronounced (100%) or severe (60%) as there was no evidence of malnutrition, anemia, debility or only fair health between exacerbations.  The 30% rating is supported when the condition is moderately severe with frequent exacerbations.  The January 2004 barium study suggested mild or inactive disease.  While the CI reported frequent bowel movements per day on a chronic basis, his on-base job performance remained excellent and he pursued scuba diving lessons.  Following the IPEB and pending his appeal to the FPEB, the CI reported exacerbations and used the bathroom more frequently at work.  However there were no documented medical encounters or objective evidence for exacerbations of the condition either with the military treatment facility or the gastroenterologist.  Following a civil service medical examination and separation, the CI returned his civil service job performing the same duties.  All members agreed, the condition was not more than moderate and exacerbations were no more than infrequent.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the UC and proctitis condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the UC and proctitis condition and IAW VASRD §4.114, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131023, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			

SAF/MRB

Dear XXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. §  1554a), PDBR Case Number PD-2013-01703.

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

							

Attachment:
Record of Proceedings