RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03876
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20061112

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E7, Tactical Unmanned Aerial Vehicle Operator, medically separated for “chronic and intermittent abdominal pain” with disability rating of 10%.

CI CONTENTION:  “Please consider all conditions.” 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 - 20060807	VARD -20071018	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic and Intermittent Abdominal Pain	7318-7301	10%	Well Healed Cholecystectomy with Residual Abdominal Pain	7318	30%	20070213	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:   

Chronic and Intermittent Abdominal Pain.  The service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 10 July 2006 indicated the CI had a left pneumonia with atelectasis (partial lung collapse) and a non-visualized gallbladder in May 2004.  The CI underwent a laparoscopic cholecystectomy for acalculous (without a stone) cholecystitis, which was followed by abdominal pain and diarrhea.  Extensive surgical evaluation noted there was a non-surgical cause of the abdominal pain.  Studies were performed including additional X-rays, a HIDA [hepatobiliary iminodiacetic acid] scan, a diagnostic laparoscopy, colonoscopy, computed tomography (CT) scans, and a magnetic resonance imaging, all of were unrevealing as to the etiology of the pain.  Evaluation at a pain clinic indicated a history of abdominal pain so severe that the CI collapsed at work and put himself into a fetal position for the pain that lasted between 2-3 minutes to a half hour.  Narcotic medications only helped in dulling the pain.  Neuropathic pain medications (Neurontin (gabapentin), Lexapro (escitalopram), and nortriptyline) and a low dose narcotic (methadone) were tried initially.  A celiac plexus block that was performed to control the pain in June 2004 provided relief for only a day.  Thereafter in October 2004, recommendations were made by a pain medicine specialist for an ERCP [endoscopic retrograde cholangiopancreatography] with a duodenal sphincterectomy (opening of the biliary duct or pancreatic duct sphincter (muscle) to remove debris), if necessary, a spinal cord stimulator, and a psychiatric evaluation.  

Post-surgical adhesions and an irritable bowel syndrome (IBS) were considered as possible causes of the pain.  Cholestyramine for the post cholecystectomy pain syndrome did not provide relief.  An upper gastrointestinal (GI) endoscopy raised the possibility of a duodenal obstruction with mild esophagitis in August 2005, while a colonoscopy was normal.  For IBS raised as the most likely GI cause of the CI’s pain tagaserod (for IBS constipation) was prescribed once, but there were no details of whether or how long it was taken.  Treatment for depression was instituted in February 2006.  A medical workup consisting of laboratory studies for celiac disease, ova and parasites and a bacterial etiology was normal.  Because of the diffuse abdominal pain, which felt crampy/colicky without nausea or vomiting, the CI was treated with narcotics including morphine and oxycodone/acetaminophen.  The diagnosis of a mood disorder due to a general medical condition was made in January 2006 and was treated with fluoxetine, an antidepressant, which was changed to Effexor XR (venlafaxine) and then to Wellbutrin XL (bupropion) in July 2006.  Remeron (mirtazapine) was prescribed to target the CI’s depressed mood and to help him gain weight and allow him to sleep.  A gastroenterologist in October 2006 found it difficult to understand why the CI had diarrhea when his colonoscopy revealed solid stool.  Gabapentin (for nerve pain) and fentanyl (a powerful synthetic opiate analgesic) were added for pain relief in January 2007.  In February 2007 porphyria, serotonin syndrome (carcinoid syndrome), and chronic pancreatitis were being considered as possible etiologies of the diffuse abdominal pain; and, the CI was referred to the pain clinic since fentanyl and morphine had poorly controlled the pain.

A permanent P3 profile was issued in April 2006 with limitations of no carrying and firing an assigned weapon and no deployment.  The commander’s statement in June 2006 indicated that the CI’s duty performance had not been impeded by his medical condition, but a coworker noted the CI had attacks of abdominal pain that came so quickly that the CI could not control his bowels or would pass out from not be able to endure the pain.  The CI worked in his primary MOS until his condition required medication that took him off flight status.  The commander also noted the CI could not carry a fighting load.  At the MEB examination dated 7 July 2006, the CI reported he had his gallbladder removed in 2004 and had chronic severe stomach pain; “lost 25 lbs in 2 years--went from 130 to 109;” and had treatment for depression. The MEB physical examiner noted on DD Form 2808 a surgical scar in the right upper quadrant, a flat abdomen with no deep tenderness to pressure, no palpable liver, no guarding, and “abdominal muscle tense.”  He also noted the CI was very thin and skinny with full affect and no change in expression.  

The NARSUM in July 2006 noted the CI related a daily, constant, sharp, pulsating 6/10 abdominal pain, which caused him to collapse and have spontaneous defecation on a weekly basis.  He had no relief with any form of treatment. The attacks occurred spontaneously without any known trigger and he was unsuccessful in isolating any particular activity.  As a result of the incapacitating abdominal pain, the CI was unable to work as an instructor.  A mental health addendum dated 17 July 2007 reviewed his depressive symptomatology; the medications he used; and therapy that did not advance his condition.  The CI was felt not to be a candidate for hypnosis.  The depressive symptoms of a depressed mood almost daily, diminished interest in pleasure, significant weight loss, problems with insomnia, psychomotor retardation, fatigue, feelings of worthlessness and hopelessness were felt to be in all likelihood due to a general medical condition of chronic pain.  The examiner noted that the degree of impairment for further military service and industrial adaptability were each marked; however, he opined that the CI “has continued to experience abdominal pain since his cholecystectomy yet psychological factors have not played a major role.” The CI Global Assessment of Functioning (GAF) was 50 (serious symptoms or any serious impairment in social, occupational, or school functioning). 

At the VA Compensation and Pension (C&P) examination dated 13 February 2007, performed 3 months after separation, the CI reported residual chronic abdominal pain after gall bladder removal that caused him to drop to the floor and lose control of his bowels with diarrhea four to six times daily.  His medications included narcotics (fentanyl patch, Vicodin (hydrocodone and acetaminophen, a pain reliever), and morphine), gabapentin, and Celebrex (celecoxib, a nonsteroidal anti-inflammatory drug (NSAID)).  The pain was described being from the rib cage to the testicles but there was no abdominal colic, nausea or vomiting, but there were signs of significant weight loss with malnutrition, anemia, and diffuse abdominal tenderness.  The diagnosis was a well healed cholecystectomy with residual abdominal pain, diarrhea, and anemia. 
 
The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 7318-7301 (gall bladder removal-moderate adhesions of the peritoneum) for chronic and intermittent abdominal pain following a laparoscopic cholecystectomy.  The VA assigned a 30% rating using code 7318 for a well healed cholecystectomy with residual pain and a 30% rating using code 7319 (irritable colon syndrome) for an irritable bowel syndrome.  The Board sought a higher rating and noted that the CI’s had severe post cholecystectomy symptoms, the etiology of which after extensive testing was not determined and which treatment failed to resolve, thereby supporting a 30% rating using code 7318.  The Board members took note of the VA ratings using code 7318 and 7319.  The post cholecystectomy syndrome does include pain and diarrhea and to use both codes seems to fall into the realm of pyramiding IAW VASRD §4.14, which is to be avoided, even though there was a thought that IBS was the cause of the pain; however, treatment for it was very limited and without effect.  The Board was unable to find a route to a higher rating in the absence of severe documented adhesions of the peritoneum.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a disability rating of 30% for the chronic and intermittent abdominal pain condition.  

BOARD FINDINGS:  In the matter of the chronic and intermittent abdominal pain condition, the Board unanimously recommends a disability rating of 30%, coded 7318 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	
Chronic and Intermittent Pain	7318	30%	
RATING	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140528, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Dear 

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the
combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board's recommendation and record of proceedings for your information.

The re-characterization of your separation as a disability retirement w\11 result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.

The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting  Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.   Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-00), 

A copy of this decision has also been provided to the Department of Veterans Affairs.

Enclosure