RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX.	CASE:  PD-2014-00387
BRANCH OF SERVICE:  Army	BOARD DATE:  20150114
DATE OF PLACEMENT ON TDRL:  20060215
Date of Permanent SEPARATION:  20071001

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Electronic Maintenance Repairer/Instructor) medically separated for ulcerative proctosigmoiditis (ulcerative colitis [UC] involving the proximal rectum and distal sigmoid colon).  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  “Ulcerative proctosigmoiditis” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB (IPEB) adjudicated “ulcerative proctosigmoiditis” as unfitting, rated 30%, citing application of the VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was placed on the Temporary Disability Retired List (TDRL) on 15 February 2006.  Approximately 20 months later, the IPEB adjudicated “colitis, ulcerative,” as unfitting, rated 10%, citing criteria of the VASRD.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Should have been disability retirement.  Was not able to fulfill commitment”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:

Final Service PEB - 20070905	VA* (2.5 Mos. Pre-TDRL Placement) 	
On TDRL - 20060215	Code	Rating	Condition	Code	Rating	Exam	
Condition		TDRL	Sep.					
Ulcerative Proctosigmoiditis →Ulcerative Colitis	7323	30%	10%	Irritable Bowel Syndrome	7319	10%	20051130	
Other x 0  (Not in Scope)	Other x 8 	
RATING:  30% → 10%	COMBINED RATING: 50%	
*Derived from VA Rating Decision (VARD) dated 20070131 (most proximate to TDRL placement); no VA rating evidence proximate to permanent separation.

ANALYSIS SUMMARY: 

Gastrointestinal Condition.  The treatment record documents that the CI complained of blood per rectum (terminal portion of large intestine [colon]) beginning in 1998.  On 23 January 1998, the CI presented to general surgery complaining of bright red blood per rectum.  The CI had previously been treated with antibiotics for a presumed infectious diarrhea.  The 5 February 1998 flexible sigmoidoscopy (lighted device for examining up to the sigmoid colon) showed inflammation, edema (swelling), and friable (fragile) mucosa (mucous membrane) of the anus and rectum.  The assessment was listed as UC (inflammatory bowel disease characterized by recurring episodes of inflammation of the mucosal layer of the colon) versus unknown.  A biopsy of the rectum was taken at 10 cm and the results showed insufficient tissue for processing.  The record then falls silent until 18 February 2004 when the CI underwent a colonoscopy, to the terminal ileum (junction of small and large intestines), for proctitis (inflammation of the lining of the rectum).  The findings were suspicious for chronic ulcerative proctitis, but other diagnoses could not be excluded.  The 18 February 2004 biopsy pathology showed active chronic proctitis.  The 14 April 2004 colonoscopy to the terminal ileum was normal.  The minimal activity in the rectum could have been concealed by the effects of corticosteroids (prednisone).  The 19 April 2005 colonoscopy showed ulcerative proctitis with multiple ulcers and edematous, erythematous (red), granular, and friable rectal mucosa to 22 cm.  The 2 August 2005 hemoglobin and iron studies (for anemia) were unremarkable.  At the 11 August 2005 gastroenterology encounter the CI complained of having five to six loose watery bowel movements (BMs) per day, with blood, clots, and mucous.  The CI reported mushy or watery diarrhea 15-30 minutes after eating.  She complained of associated stool leakage, crampy/colicky abdominal pain, nausea, and poor appetite.  She denied fever or recent weight change.  The gastroenterologist listed the diagnosis of ulcerative proctitis and opined that her current disease was not bad enough to warrant a total colectomy (surgical removal of the colon).  

In the 24 August 2005 (2 months prior to entry on TDRL) MEB narrative summary by family medicine, the CI complained of onset of symptoms in February 2004 while deployed to Iraq.  She reported onset of abdominal pain and cramps with five to seven watery and blood tinged BMs per day.  She denied a history of any problems with her intestines before.  The CI experienced symptom remission and relapse in response to medical management (oral medications, suppositories, enemas, and diet) by gastroenterology.  Surgery was not indicated.  The general physical exam was unremarkable except for mild diffuse abdominal tenderness.  Bowel sounds were normal and there were no masses or organomegaly (enlarged organs).  The diagnosis was listed as ulcerative proctosigmoiditis (inflammation of the lining of the rectum and sigmoid colon).  The 27 September 2005 medication profile showed oral, suppository, and enema variations of an anti-inflammatory medication and a probiotic.

At the 30 November 2005 Compensation and Pension (C&P) exam by family medicine, 3 months prior to TDRL entry, the CI complained of a 1-year history of constant gastrointestinal (GI) symptoms which occurred more than two thirds of the year.  The symptoms included lower abdominal pain, stomach cramps, nausea, vomiting, diarrhea, and bloody stools.  She complained of stool leakage requiring three absorbent pads per day.  The GI condition did not cause significant anemia, malnutrition, or affect her body weight.  The GI condition resulted in one day lost from work per month and functional impairment as the CI needed to be near restrooms secondary to diarrhea.  Physical exam of the abdomen showed generalized tenderness to palpitation and increased bowel sounds.  The rectal exam showed evidence of irritation but no hemorrhoids.  The diagnoses were listed as ulcerative proctitis with irritable bowel syndrome (IBS), abdominal pain and altered bowel habits in the absence of any organic cause, fecal incontinence, and multiple ulcers of the rectum.  The CI was placed on TDRL effective on 14 February 2006.  The CI was seen in a civilian GI clinic on 8 May 2007.  She reported that “in regard to her ulcerative colitis, things seem to be fine.”  She had used rectal foam for perianal itching, but the note is not clear if it was with a steroid or not.  She noted that “if anything, her intestinal track seems to be functioning better.”  The CI asked about discontinuing her medications (Mesalamine, a medicine for UC).  The examiner noted that her labs were normal including a test for anemia and inflammation.  In the 18 July 2007 (2 months prior to removal from TDRL), TDRL summary by internal medicine, the CI reported that the symptoms from her UC persisted.  She reported that she had more than four exacerbations per year and had trouble functioning in her civilian job.  The Board noted that this is not consistent with the history provided 2 months earlier.  She continued medical management for maintenance of remission.  

Physical exam showed some tenderness in the lower abdomen.  There was no evidence of anemia with normal hemoglobin and hematocrit.  The physician listed the diagnosis of UC and opined that it would likely persist, require long-term medications, and serial colonoscopy.  The physician concluded that the CI had some compensation on medications, but the UC was still in a state of flux with periodic flares.  The CI was removed from on TDRL effective on 1 October 2007.  In the 18 May 2009 VA C&P exam by internal medicine, over 19 months after TDRL exit, the CI reported being diagnosed with IBS in 2004.  She reported GI symptoms 8 months out of the year.  Symptoms included lower abdominal pain, cramping, nausea, vom-iting, belching, gas, bloating, stool leakage, frequent bowel movements, diarrhea alternating with constipation, and weight loss.  She treated the symptoms with over-the-counter medications.  The CI reported symptoms interfered with sleep, college, and church activities.  The CI denied hospitalization or surgery for this condition.  On examination, the CI was well developed and well nourished.  There was diffuse abdominal tenderness, most pronounced in the left lower quadrant.  The examiner indicated that there was no significant anemia or findings of malnutrition and opined that the condition had a mild to moderate impact on the CI’s usual occupation and daily activities.  The diagnosis of IBS was changed to the established diagnosis of ulcerative colitis.

The Board directed attention to its rating recommendation based on the above evidence.  The Board first considered its rating recommendation at the time of placement on TDRL.  The 14 October 2005 PEB rated the GI condition as ulcerative proctosigmoiditis at 30% (VASRD code 7323 colitis, ulcerative) citing moderately severe symptoms and frequent exacerbations.  All members agreed the GI condition was not pronounced (100%) or severe (60%) as there was no evidence of malnutrition, anemia, debility or only fair health between exacerbations.  A rating higher than the 30% adjudicated by the PEB is not supported by the evidence.

The Board next considered its recommendation for permanent disability rating at the time of removal from the TDRL.  The sole basis for the Board’s permanent disability recommendation is the optimal VASRD rating for disability at the time the CI is permanently separated at removal from TDRL.  The 5 September 2007 IPEB rated the GI condition 10% (7323) citing moderate symptoms and infrequent exacerbations.  The 31 January 2007 and 5 June 2008 VARDs rated the GI condition as IBS at 10% (VASRD code 7319; irritable colon syndrome) citing moderate symptoms with frequent episodes of bowel disturbance with abdominal distress.  The Board noted that the correct diagnosis should have been ulcerative colitis which was subsequently adopted by the VA.  There was no evidence of anemia or malnutrition.  Her flares were reported to be “more than four times a year,” but this was not consistent with an office visit 2 months previously.  The Board majority determined that the totality of evidence is consistent with the PEB adjudication of 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudications for the GI condition at either TDRL placement or TDRL removal.

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 condition and IAW VASRD §4.114, the Board unanimously recommends no change in the PEB adjudication at TDRL entry.  The Board, by a majority vote, recommended no change in the PEB adjudication at TDRL exit.  There were no other conditions within the Board’s scope of review for consideration.  The single voter for dissent did not elect to submit a minority opinion.

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

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140107, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

				

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXX, AR20150011004 (PD201400387)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl		     
						         
CF: 
(  ) DoD PDBR
(  ) DVA