Citation Nr: 1217680 Decision Date: 05/17/12 Archive Date: 05/24/12 DOCKET NO. 11-11 865 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to service connection for chronic fatigue syndrome, to include as a qualifying chronic disability under 3.317. 2. Entitlement to service connection for irritable bowel syndrome, to include as a qualifying chronic disability under 3.317. 3. Entitlement to an initial compensable rating for bilateral hearing loss. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD Jennifer Hwa, Counsel INTRODUCTION The Veteran served on active duty from April 1987 to April 1996. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in San Diego, California, that denied the Veteran's claims for service connection for chronic fatigue syndrome and irritable bowel syndrome and granted service connection and assigned a noncompensable disability rating for bilateral hearing loss, effective September 23, 2009. The case was subsequently transferred to the RO in Salt Lake City, Utah. In July 2011, the Veteran testified at a personal hearing over which the undersigned Acting Veterans Law Judge presided while at the RO. A transcript of that hearing has been associated with his claims file. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. FINDINGS OF FACT 1. At his July 2011 hearing before the Board, the Veteran withdrew his appeal concerning entitlement to an initial compensable rating for bilateral hearing loss. 2. The evidence is at least in relative equipoise on the question of whether the Veteran's current chronic fatigue syndrome is related to his period of service in the Southwest Asia theater of operations. 3. Resolving all reasonable doubt in the Veteran's favor, the evidence shows it is at least as likely as not that the Veteran's irritable bowel syndrome is related to his period of service in the Southwest Asia theater of operations. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the substantive appeal of the issue of entitlement to an an initial compensable rating for bilateral hearing loss have been met. 38 U.S.C.A. § 7105(b)(2) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2011). 2. Chronic fatigue syndrome was incurred in active service. 38 U.S.C.A. §§ 1110, 1117, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2011). 3. Irritable bowel syndrome was incurred in active service. 38 U.S.C.A. §§ 1110, 1117, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist VA has specified duties to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The Board has considered whether further development and notice under the Veterans Claims Assistance Act of 2000 (VCAA) or other law should be undertaken. However, given the results favorable to the Veteran, further development under the VCAA or other law would not result in a more favorable outcome or be of assistance to this inquiry. In the decision below, the Board dismisses the claim of increased initial rating for bilateral hearing loss and grants the claims of service connection for chronic fatigue syndrome and irritable bowel syndrome. The RO will be responsible for addressing any notice defect with respect to the rating and effective date elements when effectuating the awards for service connection. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Withdrawal A substantive appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. §§ 20.202, 20.204(b). Withdrawal may be made by the appellant or by his authorized representative, except that a representative may not withdraw a substantive appeal filed by the appellant personally without the express written consent of the appellant. 38 C.F.R. § 20.204(c). In April 2011, the Veteran submitted a substantive appeal perfecting his appeal as to the issue of entitlement to an initial compensable rating for bilateral hearing loss, as identified in the April 2011 Statement of the Case. At his July 2011 hearing before the Board, the Veteran stated that he was withdrawing the appeal as to the issue of entitlement to an initial compensable rating for bilateral hearing loss. The Board finds that the Veteran's statement indicating his intention to withdraw the appeal as to this issue, once transcribed as a part of the record of his hearing, satisfies the requirements for the withdrawal of the substantive appeal. Tomlin v. Brown, 5 Vet. App. 355 (1993) (a statement made during a personal hearing, when later reduced to writing in a transcript, constitutes a written notice of disagreement within the meaning of 38 U.S.C. § 7105). As the Veteran has withdrawn his appeal as to the issue of entitlement to an initial compensable rating for bilateral hearing loss, there remain no allegations of errors of fact or law for appellate consideration concerning this issue. The Board therefore has no jurisdiction to review the issue. Accordingly, the issue of entitlement to an initial compensable rating for bilateral hearing loss is dismissed. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. The law also provides that 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). In order to prevail on the issue of service connection for any particular disability, there must be evidence of a current disability; evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence, or in certain circumstances, lay evidence, of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Service connection may be established for a chronic disability manifested by certain signs or symptoms which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2016, and which, by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117 ; 38 C.F.R. § 3.317(a)(1). Consideration of a Veteran's claim under this regulation does not preclude consideration of entitlement to service connection on a direct basis. A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): an undiagnosed illness; the following medically unexplained chronic multi-symptom illnesses that are defined by a cluster of signs or symptoms: (1) Chronic fatigue syndrome; (2) Fibromyalgia; (3) Irritable bowel syndrome; or (4) Any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multi-symptom illness; or any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a). The term medically unexplained chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a). A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. 38 C.F.R. § 3.317(a). A disability referred to in this section shall be considered service connected for purposes of all laws of the United States. 38 C.F.R. § 3.317(a). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to: (1) Fatigue (2) Signs or symptoms involving skin (3) Headache (4) Muscle pain (5) Joint pain (6) Neurologic signs and symptoms (7) Neuropsychological signs or symptoms (8) Signs or symptoms involving the respiratory system (upper or lower) (9) Sleep disturbances (10) Gastrointestinal signs or symptoms (11) Cardiovascular signs or symptoms (12) Abnormal weight loss (13) Menstrual disorders. 38 C.F.R. § 3.317(b). Compensation shall not be paid under this section if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). The term "Persian Gulf Veteran" means a Veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. The Southwest Asia theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(d). In the instant case, the Veteran's Armed Forces Of The United States Report Of Transfer Or Discharge (DD Form 214) from his period of active military service from August 1988 to April 1996 shows that he had service in the Southwest Asia theater of operations during the Persian Gulf War. His military occupational specialty was that of a pilot. Therefore, the Board finds that the Veteran qualifies as a Persian Gulf Veteran. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Chronic Fatigue Syndrome The Veteran asserts service connection for chronic fatigue syndrome on the basis that he developed the condition during his period of service in Southwest Asia in the early 1990s. In support, in his statements, the Veteran reports that the condition has been chronic since that time. Service treatment records are negative for any complaints or treatment for chronic fatigue syndrome. On separation examination in December 1995, the Veteran made no complaints regarding fatigue and was not given any diagnosis relating to fatigue. In a February 2010 VA medical report for pulmonary sleep study, the Veteran indicated that he had been experiencing fatigue that had gotten increasingly worse over the past 15 years. The Veteran submitted a May 2010 lay statement from his wife in support of his claim. The Veteran's wife reported that she worked as the office manager at the Veteran's chiropractic clinic. She stated that the Veteran was exhausted every day and having difficulty working. He would sit down at lunchtime and fall asleep within minutes, sleeping so deeply that he would not return to work on time if she did not wake him. She maintained that she had to schedule fewer patients and more breaks, which was affecting them financially. The Veteran would also fall asleep if he attempted to watch a movie with his children after work. The Veteran's wife indicated that when she met the Veteran in 1991, he was already having trouble with fatigue. He had fallen asleep at the movie theater on their first date and had to hide his need to take frequent naps when working 24 to 48 hour shifts at Fort Carson. He refused to get help for his condition because he felt that it would end his military career if he complained. The Veteran's wife also reported that the Veteran's fatigue had increased dramatically in the last 4 years. In an undated letter from the Veteran's private treating physician, the Veteran was noted to have a history of extended periods of fatigue. He reported becoming severely ill with fever, chills, severe diarrhea, and muscle and joint pain during his service in the Persian Gulf. He stated that these illnesses occurred several times and that he continued to be plagued by a sore throat, chills, and alternating diarrhea and constipation upon returning to Europe. He maintained that these illnesses were not reported because they were not severe enough to warrant going to the hospital, he did not want to be grounded from flying, and he did not want to be seen as a wimp. The Veteran indicated that while specific illnesses abated, his fatigue continued. He reported that fatigue affected him daily, especially in the afternoons, and was increasingly affecting his work. The physician noted that the Veteran appeared tired. He found that the Veteran exhibited symptoms of chronic fatigue and explained that the described onset of this condition was acute with a low-grade fever and pharyngitis. The Veteran was also noted to have described credible long-lasting periods of fatigue, headaches, chronic joint pain, sleep disturbance, and neuro-psychologic symptoms. Based on the description of the area of operation in the Persian Gulf, the physician opined that it was highly likely that the Veteran was exposed to a number of pathogens and environmental agents that could cause the condition of chronic fatigue. On VA examination in March 2011, the Veteran reported having had fatigue since the early 1990s. The examiner noted the VA medical report for pulmonary sleep study where the Veteran indicated that he had experienced fatigue for the past 15 years. As a result of the sleep study, the Veteran had been diagnosed with mild to moderate sleep apnea syndrome. The Veteran reported that he was once treated for anemia. The examiner also observed that the Veteran had been treated for posttraumatic stress disorder (PTSD) and depression and that he had not slept well due to sleep disturbances from his mental health conditions for the past 20 years. The examiner noted that the Veteran had not been diagnosed with chronic fatigue syndrome. He found no symptoms of low grade fevers, nonexudative pharyngitis, palpable or tender cervical or axillary lymph nodes, generalized muscle aches or weakness, or fatigue lasting 24 hours or longer after exercise. The Veteran did have joint pains and some back pain, all of which were separate and specific diagnoses to those body regions. The examiner provided no diagnosis of chronic fatigue syndrome because he found that the Veteran did not meet the diagnostic criteria for chronic fatigue syndrome. He explained that the Veteran's fatigue was a symptom with a clear and specific etiology, namely the Veteran's sleep apnea and the sleep disturbances that he experienced due to his mental health problems. The examiner also pointed out that the Veteran was treated for anemia at one time, which also caused fatigue. He concluded that the Veteran's fatigue was due to his sleep apnea, mental health problems, and anemia, and that it was not caused by or related to a specific exposure event experienced by the Veteran during service in Southwest Asia. The Veteran and his wife testified before the Board at a July 2011 travel board hearing. Testimony revealed, in pertinent part, that the Veteran worked as a helicopter pilot, combat medic, and battalion shooting instructor during his period of service in the Persian Gulf. The Veteran testified that he was exposed to dust storms on a weekly basis in Saudi Arabia. He was also sent to observe explosions and demolition of arsenals and stockpiles of weapons as well as inspect burning oil fields. He never reported his chronic fatigue because he did not want it on his record, as it could affect whether he would get to keep flying helicopters. The Veteran stated that he would go off his post and take several naps a day in order to handle his chronic fatigue. The Veteran's wife testified that she had known the Veteran since December 1991 and that she had witnessed his constant fatigue symptoms since then. She reported that as the office manager of the Veteran's chiropractic clinic, she had to schedule more breaks so that the Veteran had time to take naps and regroup before seeing patients later in the day. She stated that the Veteran's fatigue symptoms had increasingly gotten worse. The record demonstrates that the Veteran is a Persian Gulf Veteran because he served in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(d). Moreover, the record demonstrates that the Veteran has fatigue-related symptoms. A February 2010 VA treatment record shows that the Veteran reported fatigue, as does an undated private medical report from the Veteran's treating physician. The Board also finds relevant a May 2010 lay statement from the Veteran's spouse, who details the way in which the Veteran experiences chronic fatigue. Regarding whether the Veteran has a current illness, diagnosed or undiagnosed, that relates to service in Southwest Asia, the Board finds the evidence to be in equipoise. Certain evidence indicates that the Veteran does not have a current fatigue-related illness, diagnosed or undiagnosed. The March 2011 VA examiner found that the Veteran did not meet the diagnostic criteria for chronic fatigue syndrome. He indicated that there were no symptoms of low grade fevers, nonexudative pharyngitis, palpable or tender cervical or axillary lymph nodes, generalized muscle aches or weakness, or fatigue lasting 24 hours or longer after exercise. The Veteran's joint pains and back pain were found to be separate and specific diagnoses to those body regions. The examiner concluded that the Veteran's fatigue was a symptom with a clear and specific etiology, namely his sleep apnea and the sleep disturbances that he experienced due to his mental health problems. This evidence indicates that the Veteran's fatigue symptoms are not a separate disorder, but are symptoms from his sleep apnea, psychiatric disorders, and anemia. However, other evidence reveals that the Veteran does have a distinct fatigue illness. The Veteran's private treating physician diagnosed him with chronic fatigue syndrome. He found that the Veteran did exhibit symptoms of chronic fatigue syndrome, explaining that the described onset of this condition had been acute with a low-grade fever and pharyngitis. In addition to long-lasting periods of fatigue, the Veteran was noted to have described credible long-lasting periods of headaches, chronic joint pain, sleep disturbance, and neuro-psychologic symptoms. The physician opined that it was highly likely that the Veteran was exposed to a number of pathogens and environmental agents during his period of service in the Persian Gulf that could cause the condition of chronic fatigue. In light of the lack of clarity regarding whether the Veteran has a diagnosable illness productive of fatigue that is related to service, the Veteran's and Veteran's wife's credible accounts of the Veteran having fatigue symptoms since his period of service in the Persian Gulf, and resolving doubt in the Veteran's favor, the Board finds that the chronic fatigue syndrome had its onset as a result of the Veteran's period of active service. Further inquiry could be undertaken with a view towards development of the claim so as to obtain an additional medical opinion. However, under the benefit of the doubt rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). Accordingly, the Board resolves all doubt in the Veteran's favor and finds that service connection for chronic fatigue syndrome is warranted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, the claim for service connection for chronic fatigue syndrome must be granted. Irritable Bowel Syndrome The Veteran asserts service connection for irritable bowel syndrome on the basis that he developed the condition during his period of service in Southwest Asia in the early 1990s. In support, in his statements, the Veteran reports that the condition has been chronic since that time. Service treatment records show that in April 1991, the Veteran reported diarrhea, stomach cramps, and headaches. It was noted that the other members of the Veteran's unit had experienced the same symptoms the day before but that there had been no change in diet. The Veteran was diagnosed and treated for gastroenteritis. In a medical report dated nine days later, the Veteran indicated that he had been experiencing diarrhea for nine days. He reported being given Imodium, but no antibiotics, to treat his symptoms. He stated that he had been drinking plenty of water and that he had not been eating at any Saudi restaurants. He was treated for a resurgence of diarrhea. On separation examination in December 1995, the Veteran made no gastrointestinal complaints, and he was not found to have any gastrointestinal disabilities. Post-service VA and private medical records dated from February 1996 to April 2011 show that the Veteran received intermittent treatment for unexplained occasional diarrhea, rule out microscopic colitis, dyspepsia, abdominal pain, functional bowel syndrome, and irritable bowel syndrome. In a December 1998 letter, the Veteran's private treating physician reviewed the Veteran's service records showing that while in Kuwait during Operation Desert Storm, he became stricken with very severe diarrhea which lasted 21 days. The Veteran reported that he had never had episodes of diarrhea before this other than an occasional attack of intestinal flu. The physician noted that the Veteran's severe diarrhea was treated with Imodium, Kaopectate, and antibiotics, and that no Crohn's disease, ulcerative colitis, or parasites in the stool were found. Since returning from Kuwait, the Veteran had experienced frequent episodes of diarrhea of an explosive nature that occurred twice a month and usually lasted one day at each episode. These episodes had been occurring for the preceding eight years and caused an immediate need for evacuation, which tended to decrease the severity of the symptoms. The Veteran reported that along with the diarrhea, he also had severe attacks of abdominal gas and cramping. His condition had been improved with high fiber supplements. The Veteran was noted to have contacted a gastrointestinal physiologist who felt that the severe diarrhea of 21 days that the Veteran had experienced in Kuwait had caused injuries to the microvilli, causing an irritable bowel and malabsorption syndrome. The physician agreed that this was certainly possible. He explained that the time relationship placing the first 21 day attack of diarrhea while the patient was in Kuwait with subsequent attacks on a monthly basis would tend to implicate the Veteran's service experience with his current disability. A May 1999 letter from another one of the Veteran's private treating physicians revealed that the Veteran had been treated for his chronic diarrhea since early 1997. The physician noted that the Veteran had an episode of severe diarrhea lasting 21 days during Operation Desert Storm back in late 1990 and 1991, and that prior to that episode, the Veteran had not had any previous attacks of diarrhea or any other similar type of medical illness. The physician reported that since discharge from service, the Veteran had received gastrointestinal evaluation on numerous occasions, including a barium enema, stool cultures, chemical 12 profile analysis, and complete blood counts (CBC's). Barium enema showed no evidence of Crohn's or inflammatory bowel disease. The Veteran was treated expediently for his diarrhea with Imodium, Kaopectate, and Lomodil. Over the last couple years, the Veteran continued to have frequent episodes of diarrhea and loose stools lasting in various intensity with varied degrees of severity. There was occasional abdominal cramping and pain. The Veteran had found some improvement with the use of a high-fiber, high-bulk diet. The physician noted that the Veteran had a tentative diagnosis of possible irritable bowel syndrome and malabsorption syndrome possibly caused by injuries to the microvilli when he was in Kuwait. He opined that time association with respect to the illnesses that were non-existent prior to service but very prominent afterwards seemed to indicate some tempered relationship in regards to his service in Kuwait. The physician found that the Veteran's Kuwait service could be related to his current disability. In a May 2010 lay statement, the Veteran's wife reported that the Veteran's chronic stomach pain was getting worse. She stated that he was hospitalized on Thanksgiving of the previous year and still had gotten no relief for stomach pain across his mid section, diarrhea occurring three or more times a week, nausea, gas, constipation, and high triglyceride levels which seemed to be caused by his gastrointestinal system not functioning properly. She maintained that due to his stomach pain, he had difficulty working and was constantly running to the restroom during work hours. As the office manager at the Veteran's chiropractic clinic, the Veteran's wife indicated that she had to schedule fewer patients and more breaks, which was affecting them financially. She reported that the Veteran had difficulty attending their son's lacrosse games or going camping with their son's Boy Scout group due to his gastrointestinal distress. She stated that the Veteran's medications caused side effects like headaches, the need to urinate frequently, disruption of sleep, and loss of libido and performance. The Veteran's wife indicated that the Veteran had struggled with these gastrointestinal issues since he was in the Persian Gulf in 1990. On VA examination in March 2011, the onset of the Veteran's gastrointestinal symptoms was noted to be 20 years ago when he was returning from the Gulf War. The Veteran had undergone several studies to try and discern the etiology of his symptoms, but the studies had been thus far unrevealing. He was currently experiencing abdominal pain, occasional nausea and vomiting, and alternating diarrhea, constipation, and gas. The diarrhea occurred one to three days a week alternating with constipation, and the Veteran would have two to three bowel movements a day when he had a day of diarrhea. The symptoms of abdominal pain were not completely relieved by defecation, although the abdominal pain was associated with a change in stool frequency and altered stool form. There was some straining and/or urgency. The examiner noted that the Veteran had been hospitalized twice due to abdominal pain, but no etiology had been found for his symptoms. The Veteran's treatment consisted of increasing his fiber and eating prunes, which had been helpful. The examiner diagnosed the Veteran with irritable bowel syndrome and found that his disability pattern was a chronic multisystem illness with a partially explained etiology. The examiner opined that because he had no evidence that the Veteran's disability pattern was related to a specific exposure event during service in Southwest Asia, the irritable bowel syndrome was not at least as likely as not caused by or related to any specific exposure event experienced by the Veteran during his service in Southwest Asia. His rationale was that in reviewing a book about Gulf War and Health by the Institute of Medicine, although evidence suggested a positive association between deployment to the Gulf War and irritable bowel syndrome, there was some doubt as to chance bias and confounding. Specifically, an online resource stated that the pathophysiology of irritable bowel syndrome remained uncertain. Heredity and environmental factors were likely to have a role. Many studies had reported abnormal gastrointestinal motility, visceral hypersensitivity, psychologic dysfunction, and emotional stress in patients with irritable bowel syndrome, but despite intensive investigations, the results had been conflicting, and no physiologic or psychologic abnormality had been found to be specific for this disorder. In a July 2011 letter, a private physician noted that the Veteran's severe gastrointestinal symptoms started while he was serving in the Persian Gulf during Operation Desert Storm and contracted a severe acute gastrointestinal illness lasting 21 days. He was treated with multiple antibiotics, Imodium, and aggressive hydration. The Veteran had experienced severe gastrointestinal problems since the time of his acute illness in service. The physician pointed out that prior to the Veteran's illness in 1991, he had not had a prior history of any type of chronic diarrhea, constipation, or abdominal pain conditions, nor did he have a family history of irritable bowel disease or intestinal conditions. The Veteran's current symptoms included diarrhea episodes at least four days a week, daily abdominal pain that was quite severe at times, episodes of constipation where the pain would last for one to two days, daily nausea, marked flatulence, and generalized intestinal discomfort. The physician noted that these severe symptoms affected the Veteran's ability to work as well as his ability to participate in family activities. He also reported that the Veteran had undergone numerous tests, such as barium enema, colonoscopy, multiple stool cultures for bacteria and parasites, extensive blood tests, and consultations with at least two specialists. He indicated that the entire workup had been negative for any type of structural, inflammatory, or infectious etiology for the Veteran's symptoms. Therefore, based on the severe chronic symptoms, the Veteran's gastrointestinal history, and the results of the workup, the diagnosis most consistent with the Veteran's symptoms was severe irritable bowel syndrome with malabsorption syndrome. The physician opined that this disease was more than likely caused by the Veteran's exposure to various elements during the Gulf War. He explained that the severe gastrointestinal illness that the Veteran experienced in service had more than likely resulted in his current ongoing battle with irritable bowel syndrome, most likely due to permanent damage to the lining of the intestines. He also stated that the timing of the onset of this disease was immediately following the 21 day severe illness in the Persian Gulf. The Veteran and his wife testified before the Board at a July 2011 travel board hearing. Testimony revealed, in pertinent part, that the Veteran worked as a helicopter pilot, combat medic, and battalion shooting instructor during his period of service in the Persian Gulf. The Veteran testified that he was exposed to dust storms on a weekly basis in Saudi Arabia. He was also sent to observe explosions and demolition of arsenals and stockpiles of weapons as well as inspect burning oil fields. He stated that he was treated with IV's, Imodium, and antibiotics in the hospital for horrible, dehydrating diarrhea and that he experienced horrible chills during his hospitalization. The Veteran never reported any subsequent episodes of diarrhea because he did not want it on his record, as it could affect whether he would get to keep flying helicopters. The Veteran stated that he had kept a record of his bowel movements and that he could have up to four or five bouts of diarrhea a day. He indicated that he could also have 10 to 15 episodes of flatulence before he went to work in the morning, and then when he got to work, he would have to excuse himself from his patients to find a place to release the gas. The Veteran's wife testified that she had known the Veteran since December 1991 and that she had witnessed his constant diarrhea symptoms since then. She reported that as the office manager of the Veteran's chiropractic clinic, she had to schedule more breaks so that the Veteran could run to the restroom. She stated that the Veteran's diarrhea had increasingly gotten worse. She maintained that the Veteran had constant stomach pain and cramping and that when he would have a really bad bout of diarrhea and cramping every two weeks, he would start getting chills. The record demonstrates that the Veteran is a Persian Gulf Veteran because he served in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(d). Moreover, the record demonstrates that the Veteran has irritable bowel symptoms. Post-service VA and private medical records dated from February 1996 to April 2011 show that the Veteran periodically experienced diarrhea, dyspepsia, and abdominal pain. The Board also finds relevant a May 2010 lay statement from the Veteran's spouse, who details the way in which the Veteran experiences his chronic gastrointestinal symptoms. Regarding whether the Veteran has a a current illness, diagnosed or undiagnosed, that relates to service in Southwest Asia, the Board is inclined to place lower probative value on the December 1998 and May 1999 private medical opinions because they are speculative. The December 1998 physician opined that it was certainly possible that the Veteran had irritable bowel syndrome and malabsorption syndrome and that the time relationship placing the first 21 day attack of diarrhea while the patient was in Kuwait with subsequent attacks on a monthly basis would tend to implicate the Veteran's service experience with his current disability. The May 1999 private physician found that the Veteran had a tentative diagnosis of possible irritable bowel syndrome and malabsorption syndrome possibly caused by injuries to the microvilli when he was in Kuwait, and stated that the Veteran's Kuwait service could be related to his current disability. A finding of service connection may not be based on a resort to speculation or remote possibility. 38 C.F.R. § 3.102 (2011); Bloom v. West, 12 Vet. App. 185 (1999) (treating physician's opinion that Veteran's time as a prisoner of war "could" have precipitated the initial development of his lung condition found too speculative); Tirpak v. Derwinski, 2 Vet. App. 609 (1992) (medical evidence which merely indicates that the alleged disorder "may or may not" exist or "may or may not" be related, is too speculative to establish the presence of a claimed disorder or any such relationship). Therefore, the Board places low probative weight on these opinions. Regarding the March 2011 VA opinion finding that the Veteran's irritable bowel syndrome was not related to a specific exposure event during service in Southwest Asia, the VA examiner's rationale was that in reviewing a book about Gulf War and Health by the Institute of Medicine, although evidence suggested a positive association between deployment to the Gulf War and irritable bowel syndrome, there was some doubt as to chance bias and confounding. The VA examiner based his opinion on the review of only one medical treatise, and therefore, the Board places low probative value on the March 2011 opinion. Additionally, the Board finds that in rendering the opinion, the March 2011 VA examiner failed to consider the Veteran's lay statements regarding in-service exposure to environmental agents. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination inadequate where the examiner did not comment on Veteran's report of in-service injury and relied on lack of evidence in service medical records to provide negative opinion). The Board assigns greater weight to the July 2011 private medical opinion finding that the Veteran's irritable bowel syndrome was due to his exposure to various elements during the Persian Gulf War. In placing greater weight on the July 2011 opinion, the Board notes that in forming the opinion, the physician considered the Veteran's lay statement regarding how he had only started experiencing diarrhea since his diarrhea-related illness during service. Dalton, 21 Vet. App. at 23. The physician explained that the severe gastrointestinal illness that the Veteran experienced in service had more than likely resulted in his current ongoing battle with irritable bowel syndrome, most likely due to permanent damage to the lining of the intestines. He also stated that the timing of the onset of this disease was immediately following the 21 day severe illness in the Persian Gulf. Resolving all reasonable doubt in favor of the Veteran, the Board accordingly finds the July 2011 private medical opinion to be the most probative and persuasive as to whether the Veteran's irritable bowel syndrome was due to his period of service. Accordingly, resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for the Veteran's irritable bowel syndrome is warranted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). It is noteworthy to add that the rating criteria for the Veteran's already service-connected diarrhea due to undiagnosed illness specifically include consideration of digestive impairments such as bowel disturbance, abdominal distress, diarrhea, or alternating diarrhea and constipation. See 38 C.F.R. § 4.114, Diagnostic Code 7319 (2011). On this point, the evaluation of the same disability or the same manifestations of disability under multiple diagnoses is to be avoided. 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. See also Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009) ("two defined diagnoses constitute the same disability for purposes of section 4.14 if they have overlapping symptomatology"). However, when a Veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes with different ratings. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). See also Fanning v. Brown, 4 Vet. App. 225 (1993). The critical inquiry in making such a determination is whether any of the disabling symptomatology is duplicative or overlapping. The Veteran is entitled to a combined rating only where the symptomatology is distinct and separate. Id. The precise nature and extent of his irritable bowel syndrome is not before the Board at this time. That will be a determination for the RO in the first instance. ORDER The appeal concerning the issue of entitlement to an initial compensable rating for bilateral hearing loss is dismissed. Service connection for chronic fatigue syndrome is granted. Service connection for irritable bowel syndrome is granted. ____________________________________________ DEMETRIOS G. ORFANOUDIS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs