RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00642
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20040823

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Air Force active duty E3, Aerospace Maintenance Journeyman, medically separated for “Crohn’s disease” with a disability rating of 10%.  

CI CONTENTION:  “Currently at 40% but heartburn is now real bad.”  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 - 20040406	VARD - 20050509	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Crohn’s Disease	7323-7399	10%	Crohn’s Disease with History of Gastrointestinal Bleeding	7305-7319	10%	20050315	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Crohn’s Disease.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s Crohn’s condition began in October 2003 after he experienced gastrointestinal bleeding.  However, he had two antecedent Emergency Room (ER) visits in May 2003 for left flank and abdominal pain and vomiting and nausea.  He also visited an ER in October after he vomited and had an upper gastrointestinal endoscopy that showed “lots of acid and maybe a tiny hole” that was treated with Prilosec (omeprazole, a proton pump inhibitor (PPI)).  The CI had 2 episodes of coffee ground emesis (vomiting with flecks of dark blood) 29 October 2003.  Upper gastrointestinal endoscopy (EGD) showed 7 to 8 punctate 1-2 mm ulcers oozing bright red blood in the duodenum, which were treated with argon plasma coagulation (APC).  Follow-up treatment consisted of Aciphex (rabeprazole, a PPI) and avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs).  The CI was admitted on 2 November 2003 for recurrent hematemesis (vomiting blood), melena (dark stools indicative of bleeding), and scant bright-red blood per rectum.  EGD revealed multiple, clean-based duodenal ulcers, one of which oozed small amounts of blood that was coagulated.  A serum gastrin level was slightly elevated at 128 (normal 0-100), which was attributed to being on a PPI.  PTH (parathyroid) hormone and H. pylori (bacteria that cause ulcers) tests were negative.  As a result of the gastrointestinal bleeding the CI’s hemoglobin dropped to 8 g/dL (normal 13.3-17.7) necessitating a transfusion of two units of packed red blood cells and iron replacement therapy.  On 21 November 2003, the CI reported bright red blood per rectum with tarry black stools and intermittent, loose stools.  Colonoscopy on 25 November 2003 revealed erosions in the terminal ileum and mid transverse colon and EGD revealed multiple nonbleeding punctate erosions in the gastric antrum (stomach) and the duodenum.  Biopsies of the ileum (part of the small intestine) revealed mild chronic inflammation and focal active ileitis and biopsy of the transverse colon revealed active chronic colitis with a granuloma-like reaction.  The changes were consistent with inflammatory bowel disease (e.g. Crohn disease).  Biopsies from the stomach and duodenum revealed benign gastric mucosa and foveolar hyperplasia (reactive gastritis) and focally active chronic duodenitis, respectively.  Pentasa (mesalamine) was prescribed to treat the Crohn’s disease.  

The 19 December 2003 MEB NARSUM examination, 8 months prior to separation, noted complaints of a history of gastrointestinal bleeding, initially thought to be from NSAID use, but workup and pathology revealed Crohn’s disease.  Physical examination showed a soft, flat and nondistended abdomen with minimal generalized tenderness.  On 20 January 2004, the CI reported his energy had improved and he had no more diarrhea or blood on the stools.  A small bowel follow through study dated 3 February 2004 revealed nodular fold thickening within the duodenum and terminal ileum without any ulcerations consistent with Crohn’s disease, although nonspecific.    
 
At the 15 March 2005 VA Compensation and Pension (C&P) evaluation, 7 months after separation, the CI reported a history of duodenal ulcerations and Crohn’s disease.  He had no vomiting blood, black stools, rectal bleeding, or diarrhea since 2003.  Physical examination showed the abdomen to be soft, flat, and symmetric with no masses or a palpable spleen or kidneys.  Bowel sounds were present in all quadrants.  He had slight tenderness in the right and left lower quadrants and there was no costovertebral angle tenderness.  His blood count was normal on 15 March 2005.  The CI reported coffee ground emesis and a dark stool on 27 June 2005, 9 months post-separation, when he ran out of medication.  By 19 July 2005 the CI reported he was stable on medication.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the Crohn’s condition 10%, coded 7323-7399 (colitis, ulcerative), citing the member testified that “he is currently asymptomatic and averages one non-bloody bowel movement every one to two days.”  Nevertheless, the PEB noted “the member has a chronic condition that waxes and wanes with unpredictable exacerbations, which is incompatible with the long-term rigors of military service.”  The VA rated the Crohn’s disease with history of gastrointestinal bleeding condition 10%, coded 7305-7319 (irritable colon syndrome), based on the C&P examination 7 months  after separation, citing the CI had been asymptomatic with continued medication use since his last admission in November 2003, without evidence of nausea, vomiting, diarrhea, recurrent bleeding or abdominal pain.

Panel members noted the CI was diagnosed as having Crohn’s disease, which is also known as regional enteritis or ileitis.  VASRD code 7325 (enteritis, chronic) as well as VASRD code 7326 (enterocolitis, chronic) are each rated as for irritable colon syndrome (code 7319), which for a 30% rating requires “Severe; diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress.”  However, at the time of separation and at the C&P examination, the CI was stable and did not have either diarrhea or constipation with constant abdominal distress, although he had an episode of coffee ground emesis and a dark stool 9 months after separation when he ran out of medication.  Nevertheless, within a month, the CI reported his condition was stable.  Panel members then considered whether the analogous code (7323-7399) used by the PEB, albeit it is analogous to ulcerative colitis, which is not exactly congruent with the CI’s condition, but does have overlapping symptomatology, offered a higher rating.  A 30% rating requires “Moderately severe; with frequent exacerbations,” which the CI did not have once he received and regularly took the medication for the Crohn’s disease.  Therefore, there is no route to a higher rating.  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 digestive condition.  

BOARD FINDINGS:  In the matter of the Crohn’s disease 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 20160914, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-00642.

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 appropriate.  The Board recommended no re-characterization or modification of your separation.

I carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings