RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02112
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20080712

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Small Arms Marksmanship Instructor, medically separated for “symptomatic celiac sprue in clinical but not endoscopic remission” with a disability rating of 10%.

CI CONTENTION:  Used evidence supports a higher rating.  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 - 20080603	VARD - 20081024	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Symptomatic Celiac Sprue…	7399-7323	10%	Celiac Sprue…	7399-7307	0%	20091002	
Osteoporosis	Cat II	Osteoporosis	5013	0%		
Elevated Liver Tests…		No VA Placement	
Numerous Mineral and Vitamin Deficiencies			
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:

Symptomatic Celiac Sprue in Clinical but Not Endoscopic Remission.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s symptomatic celiac sprue condition began in July 2007 with frequent bouts of watery diarrhea not responsive to Kaopectate (bismuth subsalicylate to treat diarrhea) or Imodium (loperamide to treat diarrhea).  He also noted decreased stamina with a weight loss of 20 pounds. On 7 November 2007, the CI reported approximately eight loose stools per day without other constitutional complaints.  Treatment consisted of Bentyl (dicyclomine, a gut antispasmodic medication), Imodium, and Cipro (ciprofloxacin, an antibiotic).  A stool culture and examination for ova and parasites were ordered.  On 14 November 2007, he reported 20 bowel movements per day with diffuse abdominal tenderness and nausea without vomiting and a decreased appetite.  He noted a similar episode, but less severe, 4 years earlier, which self-resolved after 1 month.  Sigmoidoscopy (to examine the anus, rectum and distal colon) was normal on 14 November 2007, but Crohn’s disease, celiac sprue, and chronic infectious causes (giardia, Entamoeba, isospora, and cyclospora) remained as diagnostic considerations.  On 16 November 2007 the CI underwent esophogastroduodenoscopy (EGD) (to study the upper gastrointestinal tract), which revealed a mosaic pattern from the bulb through the third portion of the duodenum with scalloped folds.  The examiner’s impression was probable celiac sprue.  Pathology revealed acute duodenitis (inflammation of the duodenum) with severe villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes.  At a gastroenterology follow-up visit on 10 December 2007 the examiner indicated the CI was started on a gluten-free diet and appropriate vitamin and mineral supplementation for deficiencies of vitamins A, D, E and K, folate and iron.  Since starting the diet and supplements, the CI gained 17 pounds and the diarrhea and abdominal cramping mostly resolved.  Osteoporosis (thinning of the bones) was confirmed on a DEXA (dual-energy x-ray absorptiometry) scan and calcium and vitamin D were continued and Fosamax (alendronic acid) twice weekly was prescribed.  The examiner recommended continued lifelong gluten avoidance with vitamin and mineral supplementation.  Follow-up laboratory studies were within normal ranges in March 2008, although the TTG IGA (tissue transglutaminase antibody, a marker of celiac disease) was elevated.  By 21 March 2008 the CI had gained 30 pounds and his nutritional deficiencies had had resolved.  A 1 April 2008 EGD revealed the duodenal mucosa (membrane lining of the small intestine coming out of the stomach) had improved.

The 2 April 2008 MEB NARSUM examination, 3 months prior to separation, noted complaints of celiac sprue requiring a gluten free diet.  Physical examination showed a soft abdomen with normal bowel sounds.  There was mild to moderate diffuse tenderness to palpation, but there was no guarding or rebound tenderness.  Ascites (fluid in the abdomen) was not percussed, and a liver or spleen edge was not felt.  No abdominal hernias were noted.  During the 1 May 2008 MEB examination (recorded on DD Forms 2807-1 dated 14 April 2008 and 2808), 3 months prior to separation, the CI reported damage to the upper intestine due to undiagnosed celiac sprue, uncontrollable long term chronic diarrhea, an adverse reaction to any product containing gluten, and osteoporosis due to celiac sprue.  The physical examiner checked normal abdomen and noted an anal fissure (small tear from constipation or frequent diarrhea) based on a recent examination.  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the celiac condition 10%, analogously coded 7399-7323 (colitis, ulcerative), citing three category II conditions (contributed to the unfitting condition).  The Category II listed osteoporosis, elevated liver tests felt secondary to celiac sprue, and numerous mineral and vitamin deficiencies as Category II (conditions that contribute to the unfitting condition).  The Navy cited these conditions were resolved or nearly resolved after supplementation and gluten-free diet.  The panel agreed a separate rating for any one or all of the conditions together cannot be supported without violation VASRD §4.14 (avoidance of pyramiding).  Thus, each condition was appropriately subsumed in the same rating as the celiac unfitting condition.

The VA rated the celiac condition 0%, analogously coded 7399-7307 (gastritis, hypertrophic), based on the C&P examination 15 months after separation, citing evidence of a diagnosis and treatment for this condition.  The VA also rated the osteoporosis 0%, coded 5013 (osteoporosis), citing evidence of a diagnosis and treatment for this condition; however, the CI did not report for a scheduled examination.
Members noted the CI initially presented with watery diarrhea, weight loss, and vitamin and mineral deficiencies.  However, by separation, the CI, by following a strict gluten-free diet and taking supplements of vitamins and minerals, was essentially free of diarrhea and abdominal discomfort and the nutritional deficiencies had resolved, although he still had osteoporosis, which by itself was not unfitting.  Therefore, a rating higher than 10% using code 7399-7323, which requires the disability to be “moderately severe, with frequent exacerbations,” was not in evidence at the time of separation.  However, panel members were cognizant that the pathology of the celiac sprue was located predominately in the duodenum, based on biopsy results.  While there is no code per se for that anatomical location, use of code 7399-7325 (enteritis, chronic) is not unreasonable and is rated using code 7319 (irritable colon syndrome (spastic colitis, mucous colitis, etc.), although the CI did not have Crohn’s disease.  Nevertheless, proximate to separation, the CI did not have “severe; diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress” to warrant a 30% rating.  Furthermore, panel members considered use of code 7399-7307 (gastritis, hypertrophic); however, a 30% rating, which requires “chronic; with multiple small eroded or ulcerated areas, and symptoms,” was not present nor were there symptoms at the time of separation to warrant a rating higher than 10% with the use of code 7399-7305 (ulcer, duodenal) or 7399-7306 (ulcer, marginal (gastrojejunal).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the symptomatic celiac sprue in clinical but not endoscopic remission condition.

BOARD FINDINGS:  In the matter of the symptomatic celiac sprue in clinical but not endoscopic remission condition and IAW VASRD §4.114, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150726, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC

		
							XXXXXXXXXXXXXXXXXXX
	     				Principal Deputy, Assistant 
						Secretary of the Navy
						(Manpower and Reserve Affairs)
						Performing the Duties of the 
						Assistant Secretary of the Navy
						              (Manpower and Reserve Affairs)