RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	 CASE:  PD1201869	
BRANCH OF SERVICE:  Army	 BOARD DATE:  20131224
SEPARATION DATE:  20050514		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (88M, Motor Transport Operator) medically separated for irritable bowel syndrome.  The CI began experiencing symptoms while deployed in 1991 is support of Operations Desert Storm.  He continued to experience symptoms and was treated conservatively.  He exited the active Army in 1999 and evaluated through the Veterans Administration Healthcare System.  He was given the diagnosis of irritable bowel syndrome and a disability rating of 30%.  He re-entered the Army and continued to experience problems.  In September of 2004 he was referred to the gastroenterology (GI) service at Landstuhl Regional Medical Center for more extensive evaluation and treatment.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The irritable bowel syndrome condition, characterized as not meeting standards was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB forwarded no other conditions to the PEB.  The PEB adjudicated irritable bowel syndrome as unfitting, rated 10%.  The CI made no appeals and was medically separated.  

CI CONTENTION:  “I received a medical board which resulted in my discharge from the military service due to irritable bowel syndrome at 10% disabling.  I was subsequently awarded a 30% disability from the Department of Veterans Affairs for the same disability of irritable bowel syndrome.”  

SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting irritable bowel syndrome condition is addressed below.  Any conditions or contention not requested in this application or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.  

RATING COMPARISON:  

Service IPEB – Dated 20050225	VA - (4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Irritable Bowel Syndrome	7319	10%	Irritable Bowel Syndrome	7319	30%	*20050912	
No Additional MEB/PEB Entries	Other x 2	20050912	
Combined:  10%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20051221 (most proximate to date of separation [DOS]).  Prior VA 30% rating effective 19990805 to 20010927.  
*C&P Exam dated 20050912 not available.  

ANALYSIS SUMMARY:  

Irritable Bowel Syndrome Condition.  The narrative summary (NARSUM) notes a history onset of gastrointestinal (GI) symptoms, loose stools 3-4/day and cramps in 1991.  There was a questionable exposure to nerve agent and he took anti-nerve agent pills.  Symptoms continued to the level of numerous sick call visits for GI complaints with improvement of symptoms on 2-3 Imodium per day.  He was diagnosed with irritable bowel syndrome in 1999.  Evaluations including blood and stool lab work, colonoscopy and colon biopsy did not find any other pathology (not ulcerative colitis or Crohn’s disease) aside from reflux esophagitis and a diaphragmatic hernia.  

At the MEB exam, the CI reported his current condition as having “between 4 and 22 bowel motions per day and in a typical day between 10 and 15 bowel motions.  The bowels motions are loose, almost always associated with abdominal cramping and frequently associated with rectal urgency.  Over the last year, the soldier experienced 5 episodes of stool soiling.”  The MEB physical exam noted normal physical findings including normal bowel sounds and a soft abdomen.  The NARSUM diagnosis was “irritable bowel syndrome, severe, unresponsive to normal therapy, with between 10 and 15 loose bowel motions each day associated with abdominal cramping and rectal urgency.”  

The VA rating determination dated 21 December 2005 stated “During VA examination (dated 20050912; four months after separation) you stated that you use Imodium about 8 times a day and this does not always help.  You go to the bathroom 9 to 15 times a day, which is associated with cramping and it does not seem to be exacerbated by any particular food.  Only not eating or drinking helps.”  The VA rated this exam at 30% coded 7319.  

The Board directs attention to its rating recommendation based on the above evidence.  The record clearly supports the PEB and VA diagnosis of irritable bowel syndrome and use of disability code 7319 (irritable colon syndrome, spastic colitis, mucous colitis, irritable bowel, etc.).  There was no indication of gastrointestinal surgery, anemia or overall poor health in the records.  The Board focused on rating under 7319 and deliberated if the CI’s symptoms more nearly approximated the 30% rating criteria of “Severe; diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress“ or the 10% criteria of “Moderate; frequent episodes of bowel disturbance with abdominal distress.”  Given the NARSUM characterization of severe irritable bowel syndrome and the number of daily symptomatic bowel movements with abdominal cramping and urgency, the Board considered that the symptoms were greater than the 10% “Moderate” level.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 30% for the irritable bowel syndrome condition.  

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the irritable bowel syndrome condition, the Board by a vote of 2:1 recommends a disability rating of 30%, coded 7319 IAW VASRD §4.114.  The single voter for dissent (who recommended 10% coded 7319) submitted the appended minority opinion.  There were no other conditions within the Board’s scope of review for consideration. 

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
Irritable Bowel Syndrome	7319	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20121028, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXXX, DAF
President
Physical Disability Board of Review

MINORITY OPINION:

The Service Treatment Record (STR) recounts a long history dating back to 1991 of chronic diarrhea and possible Irritable Bowel Syndrome (IBS).  In February 1992 the CI separated from service at his expiration of term of service.  He reenlisted in October 1992 and served until August 1999 when he separated due to parenthood.  His STR entries available for review during these two periods of service contain scant entries for bowel problems.  In 1999, the CI applied for and received a disability rating from the VA, which included a 30% rating for IBS.  Yet in September 2001 he again reenlisted.  On his Report of Medical History dated 17 July 2001, the CI denied having had any illnesses and denied having received any pension or compensation for any disability or injury.  He stated he was in good health.  His Report of Medical Examination dated that same day was normal with respect to the GI system and made no mention of anything related to IBS.  The CI reentered active duty.  On a Pre-Deployment Health   Assessment dated 28 March 2003 he stated his health was very good and there was no mention of anything related to IBS.  In August 2004, he reported chronic diarrhea to his Primary Care provider and was referred for GI specialty evaluation.  Objective testing and lab work was normal.  In October 2004, the CI stated he wanted to be retained, although he felt unable to continue in his MOS and the CI’s Primary Care provider counseled the CI regarding an MOS Medical Retention Board (MMRB) and initiated the first and only profile in the record for IBS (permanent P3) with a recommendation for an MMRB.  The Senior Profiling Officer/Approving Authority however directed the CI be referred to the MEB.  The PEB in its narrative on the DA Form 199, in arriving at its 10% rating, states “multiple medical evaluations and radiographic studies concluded the diagnosis to be irritable bowel syndrome although there were no physical findings on any of the examinations.  The physical and laboratory examinations were reported to be normal and a colonoscopy in October 2004 was within normal limits.”  

Additionally, performance information in the CI’s three NCOERs during his last period of enlistment does not support a conclusion that the CI’s condition was severe.  In two reports he was rated among the best and recommended for early promotions and positions of increased responsibility.  In his last NCOER that closed out in October 2004, he was again rated among the best with noted unlimited potential and a recommendation to promote.

The VASRD criteria for rating IBS are subjective with the severe rating at 30% stating there is diarrhea with more or less constant abdominal distress, and the moderate rating at 10% stating there are frequent episodes of bowel disturbance with abdominal distress.   Based on my review of the totality of the available evidence, I conclude that the CI’s longstanding condition, which he apparently performed extremely well with, did not rise to the level of severe.  While it is possible the CI had a clinical flare up of his symptoms, his reported symptoms at the time of referral to the MEB by the senior profiling officer, were inconsistent with the objective evidence and with the performance reports which gave no indication of functional impact.  There were few STR entries from August to October 2004 for IBS before referral to the MEB; and, the CI clearly felt his condition was not severe as he desired to be retained and retrained.

In conclusion, based on all of the evidence I considered, it is more likely than not that the IBS was appropriately rated 10%.  I agree with the PEB’s conclusions and therefore do not find reasonable justification for recommending a change in the PEB adjudication.  And I strongly believe there is an insufficient functional impact to support or justify the majority recommendation.  

I respectfully urge the Secretary to adopt the minority recommendation that there be no recharacterization of the CI’s disability and separation rating determination.

SFMR-RB	

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:   Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20140007197  (PD201201869)

1.	I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a, I reject the Board's recommendation and accept the Board's minority opinion as accurate that the applicant's final Physical Evaluation Board disability rating remains unchanged.  There is insufficient justification to support the Board's recommendation in accordance with Army and Department of Defense regulations.

2.	This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

	XXXXXXXXXXXXXXXXXX
Encl	Deputy Assistant Secretary
(Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA