RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01545
BRANCH OF SERVICE:  Army 	BOARD DATE:  20141120
SEPARATION DATE:  20090331

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (92A/Supply Sergeant) medically separated for sphincter of Oddi dysfunction.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty; however her profile indicated that she was eligible for alternate event physical fitness test.  She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The sphincter of Oddi dysfunction condition, characterized as “Sphincter of Oddi-dysfunction Type III with recurrent abdominal pain and transaminase elevation”, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forward two other conditions.  The Informal PEB adjudicated “Sphincter of Oddi dysfunction Type III with recurrent abdominal pain and transaminase elevation” as unfitting, rated at 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining two conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION: The CI writes: “Once I got the VA awarded me 30% for my…Oddi dysfunction”. 

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 Sphincter of Oddi dysfunction condition is addressed below and no additional conditions are 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 her service-connected condition continues to burden her; but, must emphasize that the 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 Veteran Affairs, operating under a different set of laws.

RATING COMPARISON:  

Service IPEB – Dated 20090304	VA - (10 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Sphincter of Oddi Dysfunction w/Recurrent Abdominal Pain and Transaminase Elevation	7399-7314	10%	Sphincter of Oddi Dysfunction, S/P Ball Bladder Removal	7332-7318	30%	20100128	
Other x 2 (Not in Scope)	Other x 4	20100128	
Combined:  10%	Combined:  60%	

ANALYSIS SUMMARY:  

Sphincter of Oddi Dysfunction w/Recurrent Abdominal Pain and Transaminase Elevation.  This CI initially presented to the emergency room with symptoms “urinary tract pain and painful urination” in October 2007.  Diagnostic radiographic abdominal images revealed an “incidental gall stone” in the right upper abdomen.  Later that same month the CI returned to the gastroenterology clinic with complaints of severe left upper abdomen pain.  A complete abdominal workup (CT, ultrasound, esophagogastroduodenoscopy and hepatobiliary) suggested but did not confirm the gallstones to be the source of the symptoms.  November 2007, the CI underwent a cholecystectomy (surgical removal of gallbladder), her recovery was without compilation and she was deployed to Iraq in January 2008.  While in theater, in May 2008, the CI developed left upper abdominal pain with nausea, vomiting, diarrhea with elevated liver enzymes.  The CI was medical evacuated to Germany, for further medical evaluation.  The CI’s repeat liver enzymes were within normal limits, there was no evidence of stomach/colon disorder or indication of complication related to the cholecystectomy.  Lab results for hepatitis were negative as well.  The CI returned to theater where she again became symptomatic with positive lab results again indicating elevated liver enzymes.   The CI was returned to Continental United States and assigned to a Warrior Transition Unit (WTU), Fort Knox, Kentucky.

The CI was scheduled for deployment to Iraq in May 2008 and was asymptomatic of abdominal pain and or discomfort.  In early June 2008, the CI complained of nausea, vomiting/diarrhea and was admitted to hospital on 10 July 2008, for “abdominal pain and hepatitis”.  On examination the CI was pleasant, appeared to be in no apparent distress while her abdomen examination revealed diffuse pain in the upper [abdominal] quadrant.  Diagnostic radiographic studies, to include magnetic resonance imaging, revealed no intra-abdominal pathology.  Hematology studies revealed a recurrent slight elevation of the liver enzymes but no findings of dehydration.  A magnetic resonance cholangiopancreatography obtained on 28 July 2008, revealed no biliary tract dilatation or retained gall stones.  Laboratory results for hepatitis and diarrhea-causing parasites were negative.  

The CI was evaluated by gastroenterology team on 1 September 2008, during this time the CI reported that her pain was triggered by meals.  The examiner opined that her condition and symptoms may be caused by “dysfunction of the biliary sphincter of Oddi and would require an special invasive radiographic study such as an endoscopic retrograde cholangiopancreatography (ERCP), for definitive diagnosis”.  The CI declined to have the procedure at that time, but subsequently had the procedure in January 2009; liver enzymes were within normal range.  On 9 October 2008, the CI reported to be pain free; however on 17 October 2008, she was seen for diarrhea, but did reported that she was currently taking the medication Bentyl, (treatment of irritable bowel syndrome, or spastic colon and colitis), with positive results.  The abdomen was non-tender on examination, liver enzymes were normal and without signs and symptoms of dehydration.  On 21 October 2008 the CI reported “feeling fine” no complaint of diarrhea noted, but 8 days later on the October 29 she reported some nausea after physical fitness training but no diarrhea.

The commander’s statement dated 5 November 2008 stated referred to the CI’s inability to work an full 8 hours shift due to appointments, but does state she performed her duties well, was able to attend formation; the ability to perform without an unreasonable number or duration of breaks or rest and that she sustained an ordinary routine without extra supervision.  There were no references to time missed due to hospitalization.  On the WTU visit dated 18 November 2008, the CI reported to be pain free; without any gastrointestinal symptoms and at that time taking no medication.  On the WTU visit dated 10 December 2008, the CI reported to be feeling “terrible” with a 2 day history of mild upper abdominal pain, nausea, vomiting and diarrhea; currently she was not taking any medication.  On physical examination, the CI’s vital signs were normal; weight was 149 pounds, no dehydration was present, was described as calm, pleasant, in no apparent distress and was “chewing gum.”  The abdomen was non-tender to palpation.  The examiner offered that the CI had “no need” to go to the bathroom within the 45 minute time period while in the clinic.  He also noted that the CI had been treated (2 weeks prior) for symptomatic urinary tract infection, with oral pain medication and antibiotics.  Urinary lab results revealed that the infection was persistent at the time of this examination.

At the MEB NARSUM evaluation dated 18 January 2009 (2 months prior separation), the CI reported daily “intermittent moderate left upper abdominal pain” usually followed by a loose stool.  The CI also stated that she has five to six loose stools per day (greater numbers associated with “increased stressors”) and that she took narcotic tablet for pain control, 3 to 4 times a month.  She reported visited to the emergency room or clinic at least 3 times a month, for treatment of severe pain and that the her condition required her to be hospitalized over the past 3 months; however, there was no evidence in the service treatment records of these visits or hospital admissions.  The MEB examiner noted the CI to be well nourished appeared to be in no apparent distress, did have mild upper quadrant tenderness to palpation and weight 150 pounds.  Laboratory studies indicated no dehydration or malnutrition and hepatitis studies were negative.  

During the VA Compensation and Pension (C&P) examination performed on 25 January 2010 (10 months post separation), the CI reported “frequent” diarrhea without nausea or vomiting.  She reported being unemployed and was a “homemaker” for her 3 months old child.  The CI stated that the diarrhea condition did not interfere with her daily activities but did “interfere with her quality of life”.  During physical examination, vital signs were normal; appeared to be in no apparent distress and her weight was 169 pounds.  No evidence of dehydration was noted, abdomen was soft without tenderness and laboratory results showed no evidence of dehydration or malnutrition.  

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the condition at 10% coded 7314 (chronic cholecystitis).  The 10% rating (moderate) requires infrequent attacks (not over 2 or 3 per year) of gallbladder colic (pain).  A higher rating of 30%, (severe), requires frequent attacks of gallbladder colic.  The VA rated the condition at 30% coded 7318 (gall bladder removal).  A 10% rating requires the symptoms to be “mild” and a higher rating of 30%, requires the condition to be “severe”.  The Board unanimously agreed that well-established medical principles documents that the upper abdominal pain with diarrhea and episodic elevation of liver enzymes is a known consequence of cholecystectomy and that this may occur acutely or at distant interval after surgery unrelated to known stimuli.

The Board unanimously agreed that, based on acceptable medical practice, the symptoms in this case were related to dysfunction of the sphincter of Oddi, following gallbladder surgery, given the multiplicity of normal biliary studies showing no retained stones and negative laboratory tests for hepatitis.  The Board unanimously agreed the most relevant code in this case was 7318 (gallbladder/removal).  The Board agreed that the condition initially presented with symptoms of nausea, vomiting, severe abdominal pain and diarrhea.  The Board noted the CI reporting of hospitalization dated 10 July 2008, for severe pain and emergency room visits on both the 2 June and 30 July 2008, where intravenous narcotics for pain control were administered.  However, in the period before the NARUM, the record documents the condition improving with a decrease in severe pain, nausea/vomiting and the primary symptom becoming diarrhea.  The record contained no documentation of a hospitalization for pain control or reference to the multiple clinic visits to subsequent hospitalizations until separation.  During several WTU clinic visits in October, November and December (those were prior to NARSUM), the CI reported to be feeling well and requiring no medication.  The Board notes the WTU visit on 10 December the complaint of severe pain and diarrhea were reported, but was inconsistent with the clinical findings and described status of the CI.  Additionally, the CI was under treatment for a persistent urinary tract infection at this time.  The Board noted no documentation in the service treatment record of administration of intravenous narcotics for abdominal pain during multiple clinic visits from October 2008 until separation.  On the VA’s C&P evaluation, the CI reported no abdominal pain and “frequent” diarrhea which she stated interfered with the “quality of her life” but not her ability to do “daily activities”.  The Board agreed that the preponderance of evidence in record documents no complications from diarrhea to include no chronic weight loss, no malnutrition or recurrent dehydration and no laboratory results of electrolyte imbalance.

The Board reviewed the CI’s medication profile for the 6-month period prior to the NARSUM, June 2008 to January 2009.  The Board noted the prescription for nausea, antibiotic without refills and pain medication for the recurrent urinary tract infection in both November and December 2008.  The Board noted that the CI was treated intermittently with non-narcotic medication (Benadryl and Bentyl) for control of gastrointestinal cramping.  Finally, the Board reviewed the commander’s statement dated 5 November 2008, which reflected that the CI was able to perform her duties and only missed work for scheduled clinic appointments and was without any statement of hospitalizations or emergency room visits.  

The Board considered the guidance of the VASRD in its discussions.  The Board noted VASRD code 7319, where severity of bowel function is defined.  Although this code is not specifically applicable to this case, the Board agreed the VASRD definitions were useful in assisting Board members in its considerations of a biliary case where diarrhea had become the predominant symptom.  Under code 7319 (irritable bowel syndrome), the VASRD defines “mild” as, disturbances of bowel function, with occasional episodes, of abdominal distress.  Severe is defined as diarrhea with more or less “constant” abdominal distress.  The Board agreed that the record supported the condition to be severe at its inception but to be mild to moderate at time of separation.  The members also noted no rating of “moderate” under any gastrointestinal code apropos to this condition IAW §4.114.  On detailed review, the Board furthers agreed that the record more accurately reflected a “mild condition” as opposed to a “severe condition” at time of separation as well as given the commanders statement, normalization of liver enzymes, absence of any signs of complications expected with “severe diarrhea” and reduced need for major narcotic and diarrhea controlling medication.  The Board found no other appropriate codes for consideration.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a rating of 10% code 7318.  As this code change provides no rating benefit to the CI, the Board unanimously recommends no change in the PEB adjudication.

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 Sphincter of Oddi Dysfunction 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 re-characterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
	           XXXXXXXXXXXXXXXXXX
	           President
	           Physical Disability Board of Review

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 XXXXXXXXXXXXXXXXXX AR20150006594 (PD201401545)

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						     XXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA