RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00666
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20060530

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Aerographer’s Mate, medically separated for “irritable bowel syndrome,” with a disability rating of 0%. 

CI CONTENTION:  The CI contends for his unfitting condition.  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 confined to 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 - 20060320	VARD - 20060720	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Irritable Bowel Syndrome	7319	0%	Irritable Bowel Syndrome	7319	10%	20060526	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Irritable Bowel Syndrome (IBS).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had acute onset of abdominal symptoms approximately 6 months prior to referral for MEB.  The CI presented to the emergency room complaining of a 1-day history of sudden onset of right lower right quadrant (RLQ) pain.  He reported 2 episodes of nausea and vomiting and loose stools with no blood or pus.  The CI was febrile (103.0) with exam findings concerning for an acute abdomen.  The abdominal computer tomography (CT) showed a thickened right colon (large intestine) with mesenteric fat stranding.  A colonoscopy, to the terminal ileum (small intestine), showed multiple erosions in the mid transverse colon consistent with post infectious colitis (colon inflammation).  A follow-up colonoscopy (anus to terminal ileum) a month later showed small internal hemorrhoids (dilated veins in the anus or lower rectum) but was with otherwise normal.  Random biopsies were taken.  The terminal ileum, right colon, and left colon biopsies showed disrupted fragments of ileal mucosa and benign fragments of colonic mucosa with lymphoid aggregates.  There were no ulcers, crypt abscesses, granulomas, or acute inflammation identified.  A small bowel follow through ([SBFT] X-ray that follows passage of barium through small intestine) was unremarkable.  An abdominal and pelvic CT was normal.  A gastroenterology encounter reported a history of acute abdominal pain with diarrhea that had resolved.  It documented a normal repeat colonoscopy, normal SBFT, and normal abdominal CT.  Random colonic biopsies, and all stool studies, were normal.  The assessment listed resolved gastroenteritis (stomach and intestines inflammation).  A general surgery consultation documented “I feel this patient probably has diarrheal predominant irritable bowel syndrome post infectious colitis.”  A gastroenterology encounter documented the CI had had normal bowel function until 5 months previously when he developed a severe bout of colitis (right sided colon and terminal ileum).  Those severe symptoms had resolved, but since that episode he had had classic IBS symptoms.  The CI complained of intermittent RLQ abdominal pain which was characterized as crampy and colicky.  Symptoms were related to bowel movements (BMs) and meals, and worse with fatty foods and caffeine.  The RLQ cramping was relieved with defecation.  Without medications he noted 4-5 loose to watery BMs per day with no regular bleeding.  On an antidiarrheal (Imodium [loperamide] twice a day) medication he had 1-2 loose BMs per day.  

The CI denied anorexia (decreased appetite), dysphagia (difficulty swallowing), pain on swallowing, pyrosis (heartburn), early satiety (feeling full after eating), regurgitation, nausea, vomiting, hematemesis (vomiting blood), abdominal swelling, jaundice (skin yellowing), constipation, rectal pain, tenesmus (ineffectual evacuation), melena (black, tarry stool), hematochezia (bright red blood in stool), steatorrhea (fatty stool), or acholic stools (pale, clay-colored stool).  The gastroenterologist recounted the findings of the first complete colonoscopy, which showed resolving colitis, and the normal second colonoscopy, CTs, SBFT, colon biopsies, and stool studies.  The examiner noted a 15-17 pound weight gain since the illness began secondary to difficulty maintaining an exercise regimen.  The assessment listed post-infectious IBS, with a thorough gastrointestinal (GI) workup to exclude other causes.  The NARSUM by gastroenterology, 5 months before separation, recounted the history and interventions.  The CI reported that since his severe bout of colitis, he never returned to his prior normal bowel function.  He complained of one or two loose BMs a day on medication and occasional rectal pain with diarrheal stools and cramping.  The CI denied fatigue, rash, oral ulcers, oral sores, anorexia, dysphagia, pyrosis, or constipation.  The active medication was an antidiarrheal (Imodium) twice a day.  The abdominal exam noted hernias (protrusion of organ or tissue through opening in surrounding walls) and revealed slight RLQ and periumbilical tenderness.  There was mild tenderness in the left lower quadrant (LLQ) with deep palpation.  Bowel sounds were normal and there was no distension, rebound (pain from sudden release of pressure on abdomen), guarding (abdominal wall muscle tensing), ascites (abnormal abdominal fluid accumulation), or hepatosplenomegaly (enlarged liver and spleen).  The gastroenterologist recounted the findings of the colonoscopies, CTs, SBFT, colon biopsies, and stool studies.  The diagnosis listed post infectious IBS.  

The gastroenterologist stated “This gentleman meets the criteria for post infectious irritable bowel syndrome and has had a thorough gastrointestinal workup to exclude other causes.  No further gastrointestinal workup is indicated at this time.”  The examiner opined “It is unlikely that the irritable bowel syndrome will completely resolve; tends to be an intermittent problem and will persist indefinitely in said Navy member.  However, in several cases of irritable bowel syndrome that is post infectious, there does seem to be a waxing of symptoms or waning of symptoms at 12 months.  However, this member has not quite made it to his 12 month mark.”  A sigmoidoscopy by gastroenterology was normal (normal appearing mucosa with no hemorrhoids or fissures) except for two hypertrophied anal papilla (enlarged skin tag at anal verge).  

The VA Compensation and Pension (C&P) exam recounted the history and interventions.  The CI complained of a one year history of alternating constipation and diarrhea that occurred almost every other day.  He reported occasional blood on the toilet paper.  He reported nausea but denied vomiting, fecal incontinence, fecal leakage, a fistula (abnormal passage between hollow organ and surface), or thrombosed (obstructed by clot) hemorrhoids.  The active medication was an antidiarrheal (Imodium).  The abdominal exam was normal to inspection, auscultation, palpation and percussion.  There was diffuse tenderness throughout the entire abdomen but most notable in the RUQ.  There was no guarding, rigidity, palpable mass, or hernia.  The genital/rectal exam revealed small internal hemorrhoids with no hernia, rectal fissures, or rectal ulcerations.  The examiner recounted the findings of the colonoscopies, CTs, and sigmoidoscopy.  The diagnoses listed IBS, rectal bleeding secondary to the IBS, and small internal hemorrhoids.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the code 7319 (irritable colon syndrome).  The VA assigned a 10% rating under the code 7319 based on the VA C&P exam 5 days before separation.  The VA cited a severe bout of colitis which resolved, subsequent classic IBS symptoms, 1-2 loose bowel movements per day with medication (Imodium), alternating constipation and diarrhea about every other day, thorough gastrointestinal work-up to exclude other causes, diagnosed with IBS, diffuse abdominal tenderness most notable in RUQ, no guarding, no rigidity, no palpable mass, no hernia, and mild to moderate functional impairment.  The board agreed that symptoms in the proximate exams (MEB and C&P) more closely approximated the 10% (moderate) rating with frequent episodes of bowel disturbance with abdominal distress.  The higher 30% (severe) rating would require diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a disability rating of 10% for the bowel condition.

BOARD FINDINGS:  In the matter of the bowel condition, the Board unanimously recommends a disability rating of 10%, coded 7319 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Irritable Bowel Syndrome	7319	10%	
RATING	10%	

Exhibit A.  DD Form 294, dated 20140129, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 26 Jan 16 ICO XXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 22 Jan 16 ICO XXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 12 Apr 16 ICO XXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 25 Jan 16 ICO XXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 15 Apr 16 ICO XXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (XX) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
     
     e. XXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10%) effect date of discharge.
 
     f. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.

     g. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
     h. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.