RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00491
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050329

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Healthcare Specialist, medically separated for “irritable bowel syndrome with intermittent fecal incontinence with secondary depression and anxiety,” with a disability rating of 10%.

CI CONTENTION:  The CI contends his condition continues to worsen and she received a higher rating from the VA.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 based upon a review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (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:  

SERVICE PEB - 20041216	VARD - 20050831	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Irritable Bowel Syndrome With Intermittent Fecal Incontinence With Secondary Depression And Anxiety	7319	10%	Intermittent Fecal Incontinence Secondary to Irritable
Bowel Syndrome	7399-7332	10%	20050617	
			Irritable Bowel Syndrome and Gastroesophageal Reflux
Disease S/P Cholecystectomy	7319	30%	20050617	
			Mood Disorder Secondary to General Medical Condition	9435	30%	20050617	
Primary Pulmonary Hypertension	Not Unfitting 
	Pulmonary Hypertension	7101-6600	10%	20050617	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Irritable Bowel Syndrome (IBS), Fecal Incontinence, and Depression, Anxiety.  According to the service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was diagnosed with IBS in 2004, although she had symptoms suggestive of the condition since 1997.  The CI underwent various diagnostic procedures and laboratory evaluations including colonoscopy, esophagogastroduodenoscopy, biopsies, stool cultures, antibody tests, and HIV tests; these tests were negative.  However, she was found to have a polyp unrelated to her symptoms.  Her symptoms included abdominal discomfort, diarrhea with occasional constipation and frequent episodes of fecal incontinence.  The CI reportedly experienced significant stress, anxiety and some depression secondary to the IBS, specifically, the fecal incontinence.  She was prescribed a fiber rich diet and medication for her IBS, and she received treatment at the mental health clinic to address her anxiety and depression.  Consultation with gastroenterology (GI) clinic in March 2004 noted that the CI reported she typically had a loose bowel movement (BM) 2-3 times a day, accompanied by severe urgency and frequent fecal incontinence.  She had occasional constipation, especially after severe episodes of diarrhea.  The diarrhea worsened with stress.  At the last follow-up GI visit in July 2004, the CI reported she was having 1-2 BMs daily, usually loose stools.  She usually had lower abdominal cramping that improved after the BM.  

At the NARSUM on 27 October 2004, approximately 5 months prior to separation, the fecal incontinence was the CI’s primary concern.  The frequency of BM was not recorded; however, she indicated that she had still experienced 1-2 episodes of fecal incontinence per week even when she was at home.  She indicated that she was able to control her bowels when she had immediate access to bathroom facilities.  As a result of these episodes, she had suffered from depression and anxiety, and was taking an antidepressant and anxiolytic medication prescribed by the psychiatrist.  Physical examination recorded height of 64 inches, weight of 176 pounds and BMI of 30.21.  Examination of the abdomen revealed normal active bowel sounds, no tenderness to palpation, and no palpable organomegaly or mass.  The physician opined that her condition was stable, with frequent diarrhea and occasional constipation related to IBS.  It was noted that due to the IBS, the CI was unable to adequately perform her duties, and her prognosis should be good in an occupation that does not require running, jumping or strenuous activities.  The examiner diagnosed IBS and intermittent fecal incontinence secondary to IBS, and depression and anxiety secondary to IBS.  

The VA Compensation and Pension (C&P) examination was accomplished approximately 3 months after separation.  The CI reported that she had diarrhea and or loose stools every day 3-4 times per day, but has had up to 6 loose stools a day.  She had severe abdominal cramping and pain preceding the BM which was not completely resolved after the BM.  She experienced fecal incontinence 3-4 times per week.  She noted that she required immediate access to a bathroom, and that she carried extra clothes with her wherever she went.  Physical examination documented weight of 204 pounds, reflecting a weight gain of 28 pounds in 8 months.  Examination of the abdomen demonstrated active bowel sounds with some tenderness in bilateral lower abdomen, without mass or guarding.  Rectal sphincter tone was normal.  The examiner summarized the findings noting she had loose stools and diarrhea 3-4 times a day with fecal incontinence.  At the C&P mental exam in June 2005, 1 week prior to the general exam, the CI noted that she was attending college 5 days a week.  Her daily routine consisted of waking up around 5am, going to the bathroom, exercise, return to the bathroom, shower, and dress, study a bit, and back to the bathroom one more time before driving to college at 6:30am.  She usually stopped at least once for a bathroom break along the way.  She arrived at school around 7:30; her first class was from 8-9:15, second class from 9:15-12 noon.  She sat near a door in case she had to leave to the bathroom, and she took no lunch breaks until classes ended around 2pm.  She then ate and drove home; 2 days a week she had classes until 10:30pm.  She arrived home and cared for 4 children.  
The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition described above, at 10% for moderate severity coded 7319 (irritable colon syndrome).  The VA provided a separate rating for IBS, fecal incontinence, and mood disorder secondary to general medical condition.  The VA assigned a 30% rating for the IBS, coded 7319.  The Board first deliberated whether the CI’s irritable bowel syndrome met the 10%, or the 30% 7319 rating.  A 30% rating (severe) requires diarrhea documented as severe or alternating diarrhea and constipation in a severe pattern, with constant or near constant abdominal distress.  The Board undertook a careful review of the treatment records and noted the absence of the report of constant abdominal pain. Clinical examinations noted no distress during physical exams, and examination of the abdomen was generally reported as normal.  The Board noted the record documented no malnutrition, anemia, and no weight loss, in fact weight gain was observed, no serious complications, or emergency room visits, and that the frequency of predominantly loose stools 2-4 times a day reported at the C&P examination was most consistent with a moderate degree of disease burden.  

The NARSUM examiner documented her condition was stable.  The Board opined that the evidence in the record did not approach the 30% rating criteria of 7319.  The Board unanimously agreed the preponderance of evidence supported the condition to be moderate and consistent with the 10% rating under 7319.  The Board adjudged that the CI’s condition did not support a higher than 10% disability rating.  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 IBS condition. The Board next considered the fecal incontinence and mental health conditions.  The record provided no evidence of any rectal pathology contributing to the fecal incontinence which occurred 1-2 times a week.  The Board noted the normal GI exam documented at the VA, which included examination of the rectal sphincter.  The memorandum from the treating psychiatrist to the MEB noted the CI’s condition was a co-morbid component of the IBS.  In fact, both psychiatrist (Service and VA) indicated her mental health condition was the product of the IBS.  The Board noted the psychiatrist memorandum stated the CI had baseline anxiety, and that within weeks of treatment her anxiety level was “dramatically improved.”  The CI reported feeling much better and began enjoying life.  It was noted that she was pleased with her response to the medications, but she had continued to have some residual anxiety and depression that was often related to episodes of fecal incontinence.  The psychiatrist opined that her symptoms were well-controlled, and that the CI would benefit from continued medication to maintain her well-controlled symptoms. After considerable deliberation, the Board unanimously agreed there was not a preponderance of evidence that either condition was separately unfitting.  Board members agreed, the depression and anxiety, and fecal incontinence conditions were integral, comorbid components of the IBS condition and could not be rated as single unfitting conditions IAW VASRD §4.14.(avoidance of pyramiding).  

Contended PEB Conditions:  Primary Pulmonary Hypertension.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the irritable bowel syndrome with intermittent fecal incontinence, with secondary depression and anxiety condition and IAW VASRD §4.114, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended primary pulmonary hypertension condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  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 20131201, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

26AUG2016 

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 XXXXXXXXXXXXXXXXXXXX, AR20160010614 (PD201400491)

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:
						         
Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA