RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00288
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20060728

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Machinist’s Mate, medically separated for “irritable bowel syndrome” with a disability rating of 10%.

CI CONTENTION:  “Please 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 - 20060522	VARD - 20070119	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Irritable Bowel Syndrome	7319	10%	IBS with Colitis and GERD	7399-7319	
10%
	
20060606
	
Gastroesophageal Reflux Disease	Cat II					
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Irritable Bowel Syndrome (IBS).  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s gastric condition began in January 2003 with symptoms of gastroesophageal reflux (GERD).  On 11 December 2003, a laparoscopic Nissen fundoplication was performed (to treat GERD and a hiatal hernia).  However, since January 2004, the CI reported intermittent symptoms of abdominal pain, nausea and diarrhea.  The CI also had dysphagia (difficulty or discomfort in swallowing), but had no benefit from lansoprazole (for GERD).  Low dose Elavil (amitriptyline, nerve pain medication and an antidepressant) affected him during the day and he had increased symptoms at night.  Esophagogastroduodenoscopy (EGD) was normal, but there was mild nodularity in the terminal ileum, most likely consistent with normal variant of lymphoid hyperplasia.  Mild edema and erythema were seen in the sigmoid and descending colon on colonoscopy.  Biopsies revealed chronic gastritis, normal terminal ileum and mild chronic active colitis.  Multiple medication trials failed to provide relief.  A repeat EGD on 13 December 2004 revealed several small erosions in the antrum of the stomach, but was otherwise normal.  Other than mild nodularity in the terminal ileum with normal appearing mucosa, colonoscopy was normal.  

At the gastroenterology appointment on 8 April 2005, 15 months prior to separation, the CI reported intermittent abdominal pain with 3-4 loose bowel movements per day after eating.  The gastroenterologist opined that the original colon biopsies were most like “prep artifact” and there was no further evidence of ongoing inflammatory bowel disease.  He further noted the CI’s symptoms appeared to be secondary to irritable bowel disease.  The examiner did not recommend any limitations of duty and the CI would be considered fit for overseas duty.  In July 2005, tramadol (a narcotic-like medication) was added to the treatment protocol for pain not responsive to his prescribed medications.  The CI had recurrent symptoms of GERD and chronic diarrhea that did not improve with medications. 

The 6 March 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of intermittent symptoms of diffuse abdominal pain with cramping, nausea and diarrhea.  Physical examination showed the CI to be awake, alert and in no apparent distress.  His abdomen was soft, non-tender and non-distended.  Bowel sounds were present throughout and were normal.  The liver and spleen were not enlarged.  The examiner noted the CI was unable to perform his duties due to frequent abdominal pain and diarrhea with signs and symptoms of irritable bowel syndrome.    

At the 6 June 2006 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported bowel movements within 10 minutes of ingesting any food and bilateral lower abdominal pain.  Physical examination showed four small laparoscopic scars less than 1 cm in width from the Nissen fundoplication.  They were not disfiguring, non-impairing, non-tender and without keloid formation.  Physical examination showed the abdomen to be soft.  There were no specific masses, but there was some mild tenderness of the abdominal muscles and a slight increase in bowel sounds.  There were no specific areas of abnormality.  The examiner noted the CI had ongoing GERD that was significant and contributed in a major way or was a major part of his irritable bowel disease or his hyperacidity disease.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the irritable bowel syndrome condition 10%, coded 7319 (irritable colon syndrome (spastic colitis, mucous colitis, etc.).  The Navy PEB listed gastroesophageal reflux disease condition as a related diagnosis (Category II) contributing to the disability in this case.  The panel concluded the Category II diagnosis was not a separate condition which could be reasonably justified as separately unfitting nor would a separate rating be achievable without violation of VASRD §4.14 (avoidance of pyramiding).  The VA also rated the irritable bowel syndrome with colitis and GERD conditions 10%, coded 7399-7319, based on the C&P examination 1 month before separation, citing tenderness of the abdominal muscles, three to five watery bowel movements a day, abdominal pain, intestinal pain colitis, and reflux and esophagitis. 

Members discussed whether the CI’s condition at the time of separation warranted a 30% rating, which requires “Severe; diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress.”  The panel majority agreed that a 30% rating is not unreasonable, since the CI had multiple bowel movements with diarrhea and chronic abdominal pain that was not responsive to multiple medications of various categories.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 30% for the IBS condition, coded 7399-7319.  

Contended PEB Condition:  Gastroesophageal Reflux Disease.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not listed in the Limited Duty document or implicated in the Non-Medical Assessment.  The CI had a history of symptomatic GERD and a hiatal hernia not responsive to medication and Helicobacter pylori, which was treated with triple drug therapy.  A Nissen fundoplication was subsequently performed.  Esophageal symptoms decreased, but the CI had symptoms of abdominal pain, nausea and diarrhea, which were considered after an extensive workup to be consistent with IBS as discussed above.  There was no performance-based evidence from the record that the condition 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 the contended condition; and so, no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the irritable bowel syndrome condition, the panel majority recommends a disability rating of 30%, coded 7399-7319 IAW VASRD §4.114.  The single voter for dissent recommends no change and elected not to submit a minority opinion.  In the matter of the contended gastroesophageal reflux disease condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  There are no other conditions within the Board’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	
Irritable Bowel Syndrome 	7399-7319	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160512, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 13 Oct 17 ICO XXXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXXX  
	(d) PDBR ltr dtd 28 Sep 17 ICO XXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 28 Sep 17 ICO XXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 11 Apr 17 ICO XXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 16 Jun 17 ICO XXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 25 Sep 17 ICO XXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXXX 

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (i) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXXXXXX, former USN: Placement on Temporary Disability Retired List with a 60 percent disability rating for six months at time of separation followed by a permanent disability rating of 20 percent.

     f. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 0 percent) effective date of discharge.

     g. XXXXXXXXXXXXXXXXXXX, former USMC: Placement on Temporary Disability Retired List with a 50 percent disability rating for six months at time of separation followed by a permanent disability rating of 10 percent.

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

     h. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.