RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01335
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051201

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Calvary Scout, medically separated for “esophageal stricture,” with a disability rating of 0%.  

CI CONTENTION:  He believes his condition is due to PTSD.  The applicant’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 PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the Physical Evaluation Board (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 –  20051115	VARD- 20060510	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Esophageal Stricture	7203	0%	Dysphagia	8210	30%	20060510	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY: 

Esophageal Stricture.  A note in the service treatment record (STR) dated 27 July 2004, indicated that the CI was diagnosed with “strep throat” (a bacterial infection) and was treated with a Z-pak (an antibiotic) and Augmentin (an antibiotic combination consisting of amoxicillin and clavulanic acid) to which he developed an allergy.  Additionally, he complained of dysphagia (difficulty swallowing) for about 3 to 4 months and was unable to eat any solid food, which got “hung in his throat and he had to spit it out.”  He had been “basically living on soft drink, pudding, ice cream, and since he came back to the United States, mashed potatoes.”  The assessment was pharyngitis and dysphagia for which the CI was referred to a gastro-enterologist.  On 28 July 2004, the CI underwent an esophagogastroduodenoscopy (EGD) that revealed chronic gastritis, moderate antritis (inflammation in the stomach), a hiatal hernia and a proximal esophageal stricture.  Treatment consisted of dilatation of the esophageal stricture performed to 60 French, a gastrointestinal cocktail (mixture of liquid antacid, viscous lidocaine, and an anticholinergic medication) and Protonix (pantoprazole, to treat acid reflux).  A test for the H. pylori bacteria was negative.  Ten days post-dilatation, the CI did note improvement, although he felt as though food was lodged in the back of his throat when he tried to eat macaroni and cheese.  Oropharyngeal muscular studies were obtained, which showed the musculature to be unremarkable; however a moderate amount of esophageal residue was demonstrated and multiple drinks of liquid and “dry” swallows were attempted to clear the esophagus.  An esophageal barium swallow demonstrated a mild decrease in function secondary to stripping peristaltic activity within the esophagus and no esophageal dilatation was demonstrated; however, there was a pause at the GE (gastroesophageal) junction.  Esophageal motility analysis demonstrated only 17% normal peristaltic activity, 61% hypotensive peristaltic activity, and 22% uncoordinated peristaltic activity.  On 27 August 2004, the gastroenterologist determined the CI had a non-specific esophageal motility disorder, the source of which was not clear, but presumably secondary to infection.   

At the Medical Evaluation Board (MEB) examination (recorded on DD Forms 2807 and 2808) dated September 2005, 2 months prior to separation, the examiner noted “s/p esophageal dilation” and “dysphagia.”  

The MEB narrative summary (NARSUM) dated 07 October 2005, 2 months pre-separation, noted the CI’s esophagus had no evidence to indicate restenosis (recurring abnormal narrowing), but the CI still complained of dysphagia.  The NARSUM author opined that the CI “does have a reasonable possibility of the stenosis recurring.” He added that the CI’s condition had stabilized with dilation, but he did report some difficulty with solid food.  

At a VA clinic note dated 22 February 2006, the CI complained of difficulty in swallowing that began when deployed and that he was only taking Ensure (a nutritional drink) and milk shakes.  He stated food got stuck in his throat and that he lost 10 pounds over the prior 2 months.  At the VA Compensation and Pension (C&P) esophagus and hiatal hernia examination, dated 10 May 2006 and 5 months post-separation, the CI reported being unable to swallow solids.  Besides the studies noted previously, the CI had repeat evaluations in mid-2005 which showed a medium sized hiatal hernia and LA class B esophagitis (one or more mucosal breaks > 5mm, but without continuity across mucosal folds).  Biopsies showed changes consistent with chronic reflux esophagitis and no evidence of Barrett’s esophagitis (intestinal lining replaces esophageal lining in cases of significant GERD).  On another study, there was slight impairment of esophageal peristalsis (wave-like muscle contractions that move food along the GI tract) consistent with possible gastroesophageal reflux, but not achalasia (failure of the esophageal sphincter to relax and let food pass to the stomach).  On examination, the CI had mild tenderness in the left upper quadrant.  The examiner indicated that the CI had dysphagia of an unestablished etiology.  Biopsy review was pending and the examiner noted that this was a functional problem if the biopsies did not support eosinophilic esophagitis.  However, an outpatient record dated 12 May 2006, noted no evidence of eosinophilic esophagitis.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB, citing application of Army Regulation (AR) 635-40, assigned a 0% rating using code 7203 for an esophageal stricture, status post dilation.  The VA assigned a 30% rating using code 8210 (incomplete, severe paralysis of the tenth (pneumogastric, vagus) cranial nerve) for dysphagia.  The Board sought a route for a higher rating and noted that an esophageal stricture was not present at the time of separation, but the CI had significant symptoms from the dysphagia including an inability to eat solid foods as well as regurgitation and a documented hiatal hernia.  While the VA assigned a 30% rating using a nerve code for the vagus nerve that controls peristalsis to some degree, there was no evidence in the record that studies were performed to confirm vagal nerve impairment.  Moreover, esophageal motility is a complex integration of muscular and peripheral and central neural components. Board members then discussed code 7346 (Hernia hiatal) at 30%, which covers a portion of the residual symptoms including an anatomic basis for some of gastrointestinal findings, albeit without the substernal, arm, or shoulder pain.  A 60% rating was considered; however, although the CI had weight loss, he did not have vomiting, hematemesis (blood in the vomit), melena (blood in the stools), anemia (a low blood count), or severe impairment of his heath at the time of separation.  Finally, the Board members discussed whether an analogous code 7299-7203 captures the CI’s residual symptoms of dysphagia and regurgitation post esophageal stricture dilatation.  The code 7203 is directed toward the initial esophageal stricture and the use of the analogous code permits the capture of the residual symptoms that present mainly within the realm of esophageal function, namely to move food from the throat (pharynx) to the stomach through both upper and lower sphincters.  A 50% rating for a severe condition was entertained; however, its use requires liquids only, and the CI was able to take soft foods such as mashed potatoes, although at the VA examination, he noted subsisting on Ensure and milk shakes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the status post esophageal stricture dysphagia condition.  

BOARD FINDINGS:  In the matter of the status post esophageal stricture dysphagia condition, the Board unanimously recommends a disability rating of 30%, coded 7299-7203 IAW VASRD §4.114.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Esophageal Stricture 	7299-7203	30%	
RATING	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140317, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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, AR20160005891 (PD201401335)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

	a. Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b. Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c. Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d. Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

			       
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA