RECORD OF PROCEEDINGS
PHYSICAL DISABILITY PANEL OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02132
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040712

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Infantry, medically separated for “chronic abdominal pain” with a disability rating of 10%.  

CI CONTENTION:  “Review 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 - 20040525	VARD - 20140408	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Abdominal Pain	7301	10%	Surgical Scar, Abdomen	7805	0%	20140130	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0% 	

ANALYSIS SUMMARY:  

Chronic Abdominal Pain.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s abdominal pain condition began in August 2003 when he started to complain of abdominal pain, nausea and vomiting.  The initial evaluation indicated gastroenteritis with the CI being treated with rest, nausea medication, and fluids.  However, the condition continued, leading to an Emergency Room (ER) evaluation of small bowel obstruction suggested by X-rays and clinical signs of a positive peritoneal sign, chills, right lower quadrant pain, and an inability to have a bowel movement or pass flatus (gas).  The CI subsequently underwent a small bowel resection and incidental appendectomy on 3 October 2003 whereupon the underlying cause of his symptoms was determined to be adhesion of Meckel’s diverticulum (a congenital abnormality of the small intestine, located approximately two feet before the boundary between the small intestine and large intestine) to mesentery (a double fold of peritoneum-the lining of the abdominal cavity), which caused a post-obstruction stricture.  Postoperatively, the CI continued to have significant problems, specifically with the use of MRE’s (meals ready to eat), resulting in constipation and abdominal pain.  In December 2003, the CI was evaluated in a local ER for abdominal pain with no specific findings.  In January 2004, the CI underwent a small bowel study which revealed a normal small bowel.  However, the CI continued to report significant abdominal symptoms including abdominal pain, cramps, daily diarrhea, weekly emesis (vomiting) for which there was no surgical indication.  

During 5 March 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported he still had pain from the small bowel resection.  Physical examination showed diffuse abdominal pain with soreness to palpation.  The 15 March 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of continued abdominal pain with intermittent vomiting, chronic diarrhea and cramps.  Additionally, the CI had intolerance from dairy products, protein, and large amounts of carbohydrates, which required caution with his diet.  Physical examination noted his weight was about 161 pounds and upon service entry was 159 pounds.  A midline abdominal surgical scar extending from the mid epigastrium (the upper part of the abdomen near the stomach) to the suprapubic area was present and there was diffuse soreness and pain to palpation along the scar and (above the pelvis) abdominal muscles.  Bowel sounds were present and no specific masses were found on palpation.  As result of the abdominal pain and other symptoms he was unable to perform physical exercise and training thereby restricting deployment and as well as the need for available of medical treatment.

There was no VA examination proximate to separation in evidence.  However, at the remote 30 January 2014 VA Compensation and Pension (C&P) evaluation, 9½ years after separation, which has limited or no probative value, the CI reported a variety of abdominal symptoms including loose stools immediately after eating, constipation lasting up to 4-5 days, and vomiting from overeating.  He also felt a “tearing” feeling in the mid abdomen when lifting weight with pain afterward for up to 2-3 weeks.  However, he had not been seen for those symptoms, was not taking any medication, nor did the intestinal surgery residuals impact his ability to work.  Apparently, no physical examination was performed as part of the C&P Medical Evaluation DBQ (Disability Benefits Questionnaire).

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic abdominal pain status post small bowel resection condition 10%, coded 7301 (peritoneum, adhesions-moderate), citing recurrent cramps, diarrhea, and emesis.  The VA remotely rated the chronic abdominal pain (Meckel’s diverticulum) condition not service-connected, coded 7327 (diverticulitis), based on the C&P examination 9 years after separation, citing medical evidence of the record failed to show the disability had been clinically diagnosed and that a persistent disability was not present in service; and the “Meckel’s diverticulum was removed with the surgical intervention dated October 3, 2003.  No current disability exists.”  The VA also remotely rated a surgical scar of the abdomen, which is not in the scope of review.  Panel members had a long detailed discussion of the CI’s condition at the time of separation.  The panel majority favored continued use of code 7301 (peritoneum adhesions-severe), although other codes were considered including codes 7328 (intestine, small, resection of), 7325 (enteritis, chronic-rate as irritable colon syndrome), and 7319 (irritable colon syndrome (spastic colitis, mucous colitis, etc.).  Panel members noted that the VA used the code 7327 (diverticulitis) for the CI’s condition that began with a residual Meckel’s diverticulum, which is also rated as irritable colon syndrome.  The CI experienced significant postoperative abdominal symptoms including abdominal pain, cramps, daily diarrhea, weekly emesis (vomiting) proximate to separation, which despite a more than 9 year hiatus to the C&P DBQ, continued in the form of loose stools immediately after eating, constipation lasting up to 4-5 days, and vomiting from overeating as well as a tearing pain in the abdomen when lifting, which lasted for weeks.  A 30% rating using code 7301 (moderately severe; partial obstruction manifested by delayed motility of barium meal and less frequent and less prolonged episodes of pain) is not an unreasonable consideration; however, no evidence of a partial obstruction was demonstrated in the record postoperatively, although it was present preoperatively; not withstanding that constipation occurs as a result of delayed motility, but that is not its exclusive cause.  Code 7328 (intestine, small, resection of) warrants a 40% rating “with definite interference with absorption and nutrition, manifested by impairment of health objectively supported by examination findings including definite weight loss,” while a 20% rating requires the CI to be “symptomatic with diarrhea, anemia and inability to gain weight.”  However, while the CI was symptomatic with diarrhea, he had neither anemia nor an inability to gain weight” nor was there a significant weight loss from service entrance to separation, albeit there was a fluctuation postoperatively, there was no significant weight loss at separation to warrant a 40% rating or an inability to gain weight for a 20% rating.  Panel members noted that code 7325 for enteritis, an inflammatory condition of the intestine is rated as 7319 and has symptoms similar to the CI’s status post-surgical resection of the Meckel’s diverticulum and code 7319 offers a 30% rating option (severe; diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress), although the panel majority felt the CI symptoms were more consistent with a 10% rating rather than a 30% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic abdominal pain condition.  

BOARD FINDINGS:  In the matter of the chronic abdominal pain condition and IAW VASRD §4.114, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  There were 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 20150622, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

	

Minority Opinion.  The CI’s symptoms status postsurgical removal of a Meckel’s diverticulum were significant and included abdominal pain with intermittent vomiting, chronic diarrhea and cramps.  Additionally, the CI had intolerance from dairy products, protein, and large amounts of carbohydrates, which required caution with his diet.  In essence his intestinal tract never satisfactorily normalized postoperatively, and in fact, he was still symptomatic 9½ years after separation.  While his postoperative symptoms may have been secondary to adhesions, which was not proved definitively; nevertheless, there was an adhesion noted at the time of surgery in the area of the Meckel’s diverticulum.  However, his symptoms are clearly spelled out for a 30% rating using code 7319 and were more severe than a 10% rating that code 7301 offered.  Therefore, the minority voter recommends use of an analogous code 7328-7319, which includes and reflects the small bowel surgery and the postoperative symptoms related thereto and which more clearly addresses and more accurately rates his symptomatic condition at the time of separation, and although not probative for rating purposes, his symptoms continued unabated well beyond separation.  

Therefore, the minority voter recommends that the ROP be modified to read:

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 chronic abdominal pain condition, coded 7328-7319.  

In the matter of the chronic abdominal pain condition, the panel recommends a disability rating of 30%, coded 7328-7319 IAW VASRD §4.114.  

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	
Chronic Abdominal Pain	7328-7319	30%	

AR20170010045, XXXXXXXXXXXXXXXXXX 

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Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,