RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01041
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20070409

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Financial Management and Comptroller, medically separated for “functional abdominal pain syndrome,” with a disability rating of 10%.

CI CONTENTION:  He requests review of all conditions.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20070123	VARD – NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Functional Abdominal Pain Syndrome	7399-7301	10%	No VA Examination in Evidence	
Bilateral Patellofemoral Syndrome	Cat II		
Chronic Low Back Pain			
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Functional Abdominal Pain Syndrome.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s abdominal pain syndrome condition began in April 2006 after undergoing an appendectomy on 27 April 2006 for an acute non-ruptured appendicitis.  On follow-up he noted diarrhea after eating greasy foods and occasional nausea. Because of continued post-prandial (after eating) right upper quadrant pain, an esophagogastroduodenoscopy (EGD) was performed, which revealed chronic gastritis and duodenitis (inflammation of the duodenum).  Empiric antibiotic treatment for H. pylori (a bacteria known to cause gastric and duodenal ulcers) was instituted, but was discontinued when no H. pylori was detected on biopsy.  A HIDA [hepatobiliary iminodiacetic] scan (imaging of the liver, gallbladder and bile ducts) demonstrated lack of gallbladder contraction consistent with biliary dyskinesia.  Colonoscopy was normal, although the terminal ileum (of the small intestine) was not visualized.  The CI then underwent a laparoscopic cholecystectomy to remove his gallbladder on 14 July 2006. However, he continued to have daily abdominal pain in the upper abdominal area within 20 minutes after awakening.  He had diarrhea without mucus or blood.   The CI initially lost no weight, but did so subsequently.  He denied fever, chills, arthralgias, arthritis, rash, cough, chest pain and shortness of breath.  Laboratory studies were negative for C. difficile (pathogenic bacteria that cause diarrhea), ova and parasites, and stool white blood cells, and a stool culture was negative for pathogenic bacteria.  He was treated with Bentyl (dicyclomine an antispasmodic medication), Carafate (sucralfate, an antacid to treat duodenal ulcers), and Zantac (ranitidine, an antihistamine to treat stomach ulcers and GERD), but they were discontinued due to lack of improvement and were replaced with Actigall (ursodiol, a bile acid).  Imodium (loperamide to treat diarrhea) was continued as needed.  At as surgical evaluation on 15 August 2006 because of persistent symptoms, a functional etiology was raised and the CI was started on Pamelor (nortriptyline, a nerve pain medication and antidepressant). A further extensive workup (celiac sprue serology (endomysial antibodies), AM (morning) cortisol, amylase, lipase, sedimentation rate (ESR), C-reactive protein (CRP), B12 and folate levels, clotting studies, iron studies, urine porphyrins, heavy metal screen, fecal fat and HIV) was all normal.  An inflammatory bowel disease panel was negative for neutrophil specific antibody (a test for ulcerative colitis); and ASCA (anti-saccharomyces cerevisiae antibody) IgG was negative, but ASCA IgA was positive.  Biopsies of the terminal ileum and colon were performed on 28 August 2006.  Computerized tomography (CT) of the abdomen and pelvis with a pancreatic protocol was normal as was a small bowel follow through. The CI noticed improvement with steroids; however, when stopped, he had constant abdominal cramping five to six times a day mainly over the right upper quadrant.  On 8 November 2006, he underwent colonoscopy and push enteroscopy (to assess for small bowel Crohn’s disease), which showed mild distal esophagitis and a small to medium hiatal hernia with mild to moderate patchy antral erythema (of the stomach) and a normal terminal ileum.  Biopsy results of the stomach, jejunum, small bowel, terminal ileum, and colon were all normal.  

At a 4 December 2006 internal medicine visit the CI reported he had lower abdominal pain of 5/10 (10 being the worst pain) intensity with cramping and bloating, which was “manageable.” He also had two bowel movements a day that were soft to liquid without blood or mucus.  He had GERD (gastroesophageal reflux disease) pain of 8-10/10 and noted worsening after changing from Prilosec (omeprazole) to Aciphex (rabeprazole).  Symptoms were better on a gluten free diet.  

The 6 December 2006 MEB NARSUM examination, 4 months before separation, noted complaints of persistent gastrointestinal symptoms over the prior 8 months.  The CI was unable to do PT and all portions of the fitness test.  He had recently returned to work full time, but continued to have flares of pain and fatigue that required ER (Emergency Room) visits and Quarters authorization.  He had no evidence of inflammatory bowel disease.  

At an ER visit on 29 January 2007 the CI complained of right lower quadrant pain.  On examination his abdomen was soft and non-distended without guarding or rebound, but with diffuse tenderness and negative psoas and obturator signs (to determine appendicitis).  Treatment consisted of intravenous fluids and Toradol (ketorolac, a nonsteroidal anti-inflammatory drug (NSAID)) for pain relief.  There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the functional abdominal pain syndrome coded analogously 7399-7301, (peritoneum, adhesions of).  Panel members noted that a rating for adhesions is considered when there is a history of operative or other traumatic or infectious (intraabdominal process), and at least two of the following:  disturbance of motility, actual partial obstruction, reflex disturbances, or presence of pain.  A rating of 30% for peritoneal adhesions using code 7301 requires “moderately severe; partial obstruction manifested by delayed motility of barium meal and less frequent and less prolonged episodes of pain,” while a 50% rating requires “severe; definite partial obstruction shown by X-ray, with frequent and prolonged episodes of severe colic distension, nausea or vomiting, following severe peritonitis, ruptured appendix, perforated ulcer, or operation with drainage.”  Although the CI had two abdominal surgical procedures (appendectomy and cholecystectomy), no follow-up studies were performed to determine whether there were peritoneal adhesions, and if so, to what extent, although more likely than not, they were present.  A barium study also was not performed to determine motility status; however, the CI did have episodes of pain for which he sought ER care on many occasions.  Although, extensive studies failed to find an etiology for the abdominal pain and the diagnosis of functional abdominal pain syndrome was made, nevertheless, the CI’s condition was more closely related to moderately severe than to moderate prior to separation.  Alternatively, the 7318 code (gallbladder, removal of) offers a 10% rating with mild symptoms and a 30% rating for severe symptoms.  Because the CI had continuous pain both preoperatively and postoperatively, to consider the CI’s symptoms severe is not unreasonable since he had both upper and lower gastrointestinal symptoms that were not controlled with multiple medications and were marked by crampy abdominal pain and diffuse tenderness suggestive of a post cholecystectomy syndrome, although not diagnosed as such.  While he considered the condition “manageable,” he was frequently out of work and still had medical and ER visits for pain.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the functional abdominal pain syndrome condition, coded 7399-7318.  

Contended PEB Conditions-Bilateral Patellofemoral Syndrome and Chronic Low Back Pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Neither of the conditions were profiled proximate to separation although there was an L3 profile for a left knee injury in February 2004 and neither was explicitly implicated in the commander’s statement.  Both conditions were determined to be Category II (conditions that can be unfitting but are not currently compensable or ratable).  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions; and so, no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the functional abdominal pain syndrome condition, the panel unanimously recommends a disability rating of 30%, coded 7399-7318 IAW VASRD §4.114.  In the matter of the contended bilateral patellofemoral pain syndrome and chronic lower back pain conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.  

The panel 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Functional Abdominal Pain Syndrome	7399-7318 	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, w/atchs
Exhibit B.  Service Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01041.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay

I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at XXXXXXXXXXXXXXXXXXX to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings