RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00461
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20060724

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

CI CONTENTION:  His condition continues to worsen and negatively impact his daily activities.  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 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 - 20060601	VARD - 20070118	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Abdominal Pain	7301	10%	Irritable Bowel Syndrome, Mild Antritis, and Atrophic Gastritis	7399-7319	30%	20060817	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Abdominal Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s abdominal condition began in January 2005 after being struck in the abdomen by a mounted machine gun when his vehicle hit a rough spot during a training exercise.  Initial evaluation by endoscopy revealed non-erosive gastritis and an ultrasound of the abdomen showed an abnormal finding near the pancreas.  Computerized tomography (CT) confirmed an abdominal mass around the pancreas.  On 23 May 2005 the CI underwent exploratory laparotomy which found a moderate-to-large sized pancreatic pseudocyst.  Surgery consisted of a cystogastrostomy (an opening between a pancreas and stomach to drain the cyst).  The pathology final diagnosis noted changes consistent with a pseudocyst.  The CT dated 28 June 2005 demonstrated no evidence of recurrence of the large pancreatic pseudocyst.  However, he continued to have epigastric abdominal pain that was worse with meals and caused anorexia.  

Studies revealed a normal biliary panel, normal amylase/lipase, and a normal upper gastro-intestinal study with a small bowel follow-through and a negative right upper quadrant ultrasound.  An EGD (esophagogastroduodenoscopy) on 29 August 2005 showed mild antritis (inflammation of the antrum (distal portion of the stomach)), which was treated with proton pump inhibitor medications.  A biopsy for Helicobacter pylori was negative.  A hepatobiliary scan on 7 September 2005 indicated the gallbladder was not visualized, which was interpreted as an abnormal study consistent with acute cholecystitis (inflammation of the gallbladder).   A repeat study on 30 September 2005, performed because of a change of symptoms, had the same findings.  On 19 October 2005 he complained of intermittent right upper quadrant pain that radiated to his right surprascapular area and was worse after meals.  He underwent a laparoscopic cholecystectomy on 28 October 2005 for biliary dyskinesia (dysfunction of motility of the gallbladder).  Pathology revealed chronic cholecystitis; gallbladder stones were not present.  Pain persisted and on 15 December 2005 he underwent exploratory laparoscopy with lysis of adhesions.  The CI had worsening left upper quadrant abdominal pain, but a CT scan on 20 December 2005 revealed no intra-abdominal pathology other than free gas throughout the abdomen anterior to the stomach on the basis of recent postoperative changes.  Treatment consisted of Percocet (oxycodone, a narcotic, and acetaminophen, a pain reliever) and Colace (docusate sodium, a stool softener). However he continued to have symptoms of loose stools after eating and occasional vomiting. The pain transitioned to the left upper quadrant primarily worse with eating as well as running, sit-ups, and even walking.  Magnetic resonance imaging (MRI) of the pancreas was ordered to evaluate the chronic abdominal pain.

The 24 February 2006 MEB NARSUM examination, 5 months prior to separation, noted complaints of chronic abdominal pain in the upper abdomen as a constant throbbing pain, occasionally radiating to his back, which was aggravated at times by food intake and by movement.  Physical examination of the abdomen showed a mid-line scar from previous surgery with positive bowel sounds.  The abdomen was soft, but he did have tenderness in the upper abdomen with some guarding, but no rebound was present and no masses were detected.

During the 29 March 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported he “had abdominal surgery/cyst removal, gall bladder removed—constant diarrhea, intermittent vomiting after meal,” was “not in good health due to chronic abdominal, indigestion problems,” and that he had “pain after eating and physical activity, or laying on stomach or side.”  Physical examination showed abdominal tenderness, without rigidity or guarding and positive bowel sounds in four quadrants.  There were multiple superficial abdominal scars “on long vertical” and multiple laparoscopy scars.

At the 17 August 2006 VA Compensation and Pension (C&P) evaluation, 1 month after separation, the CI reported left-sided abdominal pain, mild to moderate, lasting for 30 minutes, either relieved spontaneously or when he took Percocet or tramadol (an opioid-like medication).  He also complained of loose bowel movements every other day especially with meals, and sometimes with tarry stools as well as nausea and vomiting with some blood-tinged vomitus, especially at the end of his vomiting.  Physical examination showed the abdomen to be flat, firm, and non-tender.  There was tenderness overlying the scar (on the midline of the abdomen, 18 cm x 1 cm (1.5 cm in its greatest width)) and surrounding the periphery of the scar.  Bowel sounds were 1+ and there were no bruits (abnormal sounds) or ventral hernias.    

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the abdominal condition 10%, coded 7301 (peritoneum, adhesions), citing a necrotic hemorrhagic pancreatic pseudocyst with surgery including cholecystectomy and adhesiolysis (removal of adhesions).  The VA rated the abdominal condition 30%, coded 7399-7319 (irritable colon syndrome), based on the C&P examination 1 month after separation, citing evidence of surgical procedures and diagnostic testing which showed evidence of irritable bowel syndrome, mild antritis, and gastritis.  

Members noted that despite extensive investigative studies and multiple surgical procedures, the CI continued to be symptomatic with abdominal pain, loose bowel movements or diarrhea, and vomiting after eating or after exercise of an uncertain etiology.  Code 7319 offers a 30% rating for “severe, diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress;” however, the CI’s pain was in the upper quadrants of the abdomen.  Code 7318 (gallbladder removal) likewise offers a 30% rating with severe symptoms, which is what he had proximate to separation.  Furthermore, he underwent lysis of abdominal adhesions.  Therefore, use of code 7301 is not unreasonable; however, a 30% rating requires the disability to be “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.”  However, the CI neither had a barium meal to demonstrate delayed motility nor X-rays to demonstrate a partial obstruction.  Members noted that the CI’s condition at the time of separation warranted at least a 30% rating; therefore, use of code 7318 is applicable since postoperatively the CI had severe symptoms necessitating lysis of adhesions and diarrhea with intermittent vomiting.    

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 abdominal condition, coded 7318.  

BOARD FINDINGS:  In the matter of the abdominal condition, the panel unanimously recommends a disability rating of 30%, coded 7318 IAW VASRD §4.114.  There are no other conditions within the panel’s scope of review for consideration.  The panel recommends 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	
Removal of Gall Bladder with Severe Symptoms	7318	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160719, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170015669, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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 will 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-DO), XXXXXXXXXXXXXXXXXXX.

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

Sincerely,					      
Enclosure