Citation Nr: 0205499 Decision Date: 05/28/02 Archive Date: 06/03/02 DOCKET NO. 99-18 743 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Wilmington, Delaware THE ISSUE Entitlement to service connection for irritable bowel syndrome (IBS). WITNESSES AT HEARING ON APPEAL Appellant and her spouse ATTORNEY FOR THE BOARD K. Hudson, Counsel INTRODUCTION The veteran served on active duty from February 1993 to February 1996. This appeal comes before the Board of Veterans' Appeals (Board) from an RO rating decision in June 1998 which denied service connection for IBS. In August 2001, this issue was remanded to the RO for additional development. The appeal has been advanced on the docket due to her serious illness. FINDINGS OF FACT IBS had its onset during the veteran's active service. CONCLUSION OF LAW IBS was incurred in active service. 38 U.S.C.A. § 1110 (West 1991 & Supp. 2001); 38 C.F.R. § 3.303 (2001). REASONS AND BASES FOR FINDING AND CONCLUSION A. Factual Background The veteran served on active duty in the Navy from February 1993 to February 1996. Service medical records reflect that the veteran was treated in October 1994 for severe diarrhea. In July 1995, she was diagnosed with breast cancer, and metastatic cancer in the right axillary lymph nodes. She underwent a modified radical mastectomy of the right breast in July 1995, and was started on chemotherapy in September 1995. VA medical treatment notes indicate that the veteran underwent six months of chemotherapy after the mastectomy surgery. In February 1996, the veteran was placed on temporary retirement from service because of disability due to her cancer and cancer treatment. VA outpatient treatment notes indicate that the veteran was started on Tamoxifen in April 1996. On VA medical examination in July 1996, her complaints included abdominal pain. The examiner did not find any evidence of disorders of the digestive system. The examiner reported that the veteran was status post Stage II, Grade III right breast cancer, status post modified radical right mastectomy and chemotherapy. In December 1996, the veteran underwent a transverse rectus abdominis muscle (TRAM) flap reconstruction of the right breast at a VA Medical Center (VAMC). After the reconstruction surgery, infection developed in the surgical wound, which necessitated surgery to debride and irrigate the TRAM flap in January 1997. Notes dated in April 1997, from Asher B. Carey, M.D., a private plastic surgeon, reflect the veteran's report of discomfort in the entire abdominal area. She indicated that after walking up about four stairs, or walking about two blocks, she had severe abdominal pain that lasted about twenty minutes, and was relieved only by lying down. She reported that the abdominal discomfort was worsening. Dr. Carey noted weakness over the abdominal area, without herniation. VA medical treatment notes reflect the veteran's report, in August and September 1997, that she had abdominal cramps, especially after walking and going up and down stairs. In October 1997, private orthopedist John E. Speiker reported that he had evaluated the veteran. He noted that the veteran's right breast reconstruction surgery had used rectus abdominis muscle transfer to reconstruct the breast, and that she had since lost most of her muscle tone through the abdomen. Dr. Speiker reported, "Bowel and bladder function have also been affected secondary to her lack of abdominal muscle tone and the inability to perform a Valsalva." In a VA gastroenterology examination performed in November 1997, the veteran reported that difficulty rising from a supine position, constipation, and blood in her stools. She reported that those problems had developed since her abdominal surgeries in 1996 and 1997. In March 1998, private gastroenterologist Brent W. Geissinger, M.D., wrote that he was treating the veteran for GERD and IBS. Biopsies taken in May 1998 showed malignancy in the right breast. Subsequent records show treatment with chemotherapy. On VA examination in October 1998, the veteran reported that over the past three years, dating since the treatment for breast cancer, she had noticed on a continuing daily basis, cramping, bloating and discomfort of the lower abdomen. She also reported alternating symptoms of loose stools with constipation. During periods of constipation, blood was associated with her bowel movements. A history of diverticular disease by colonoscopy on 1997 was noted. On examination , there was some tenderness to deep palpation on both side of the abdomen. The assessment was that by clinical criteria, she had irritable bowel syndrome, manifested by diarrhea, constipation, and abdominal pain. In response to a request for an opinion, the physician wrote, "There is no discernible cause for irritable bowel syndrome, so it is difficult to attribute that the chemotherapy directly caused her symptoms." The physician further noted that in many instances, IBS was a chronic disorder. Another VA examination in October 1998 noted that the veteran had problems with constipation. She had a great deal of medical problems, and was under a great deal of stress. Depression was diagnosed. In April 1999, private oncologist Lamberto M. Arellano, M.D., reported that the veteran was currently under treatment with chemotherapy for breast cancer. The veteran had a hearing at the RO in October 1999. She noted that she was under treatment for a recurrence of cancer, and she asserted that she had loss of use of her legs because of the disability of her abdominal muscles following surgery. She asserted that she had IBS caused by her chemotherapy drugs. Treatment notes from Dr. Arellano reflect that the veteran had recurring, persistent residual carcinoma in the chest wall in January 2000. In August 2000, Dr. Arellano noted that the veteran had received six cycles of chemotherapy, most recently in July 2000. In July 2001, the veteran and her husband testified at a hearing before the undersigned Board Member at the Board's offices in Washington, D.C. She reported that she had constipation and IBS as a result of the pain medications that she took. On a VA examination in September 2001, the veteran game a history of chronic constipation for four years. She also had abdominal pain and cramps. A colonoscopy in June 2000 reportedly showed diverticula and internal hemorrhoids. Physical examination of the abdomen was normal, except for the surgical scar. The assessment was chronic constipation, likely due to IBS. The examiner noted that the etiology of irritable bowel syndrome was unknown, and there was no known association between IBS and cancer chemotherapy. Her constipation, however, may be exacerbated by the narcotic pain medication she takes. Also of record is an excerpt from The Merck Manual of Diagnosis and Therapy, which notes that the cause of IBS is unknown. Emotional factors or drugs may precipitate or aggravate heightened gastrointestinal motility. Some IBS patients also had anxiety disorder, and some appeared to express emotional conflict as a gastrointestinal complaint. The Merck Manual, 312 (17th ed. 1999). Other articles obtained from internet research are also of record. As a result of the most recent rating decision, dated in February 2002, the veteran is currently service-connected for the following disabilities: postoperative residuals of breast cancer and right radical mastectomy, evaluated 100 percent disabling; loss of use of both lower extremities, evaluated 100 percent disabling; PTSD, evaluated 50 percent disabling; right arm weakness due to axillary lymph node dissection, assigned a 40 percent rating; neurogenic bladder, assigned a 40 percent rating; postoperative abdominoplasty weakness, assigned a 30 percent rating; GERD with duodenitis, assigned a 10 percent rating; limited right ankle motion, assigned a 10 percent rating; donor site scar, status post TRAM (transverse rectus abdominis muscle) flap surgery, assigned a 10 percent rating, and endometrial atrophy, evaluated noncompensably disabling. She also receives several special monthly compensation awards. B. Analysis The veteran has been notified of the evidence necessary to substantiate her claim and of the applicable legal criteria. She has testified at a hearing pertaining to the issue on appeal. VA examinations have been provided. All essential records have been obtained, and the veteran has not identified additional pertinent records. The Board is satisfied that the notice and duty to assist provisions of the law have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West Supp. 2001); 66 Fed. Reg. 45,620, 45,630 (Aug. 29, 2001) (to be codified at 38 C.F.R. § 3.159). Service connection may be established for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The veteran contends that IBS developed as a side effect of chemotherapy and/or pain medication she takes for treatment of her service-connected breast cancer. However, under the circumstances the Board finds no need to address the theory of secondary service connection under 38 C.F.R. § 3.310. The medical records from during and after service demonstrate numerous abdominal and bowel symptoms due to various causes; there is now a clear diagnosis of IBS; and there is a reliable history of IBS-type symptoms ever since the veteran was on active duty. There appears to be a reasonable basis to trace IBS back to service, even if the condition was not diagnosed until after service. With application of the benefit-of-the-doubt rule, 38 U.S.C.A. § 5107(b), the Board finds that IBS began during the veteran's active duty. The Board concludes that the condition was incurred in service, and service connection is warranted. ORDER Service connection for IBS is granted. L. W. TOBIN Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.