Citation Nr: 1339397 Decision Date: 12/02/13 Archive Date: 12/13/13 DOCKET NO. 10-36 248 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for a gastrointestinal disorder, claimed as ulcerative colitis, to include as secondary to a service-connected skin disorder. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD S. D. Regan, Counsel INTRODUCTION The Veteran had a period of active duty for training in the Army Reserve from September 1975 to February 1976, as well as active duty in the Army from April 1976 to November 1980. In a February 1982 Administrative Decision, the Veteran's character of service for the period from April 2, 1976 to April 1, 1980, was found to be honorable and entitlement was established to all benefits administered by VA. The Veteran's character of service for the period from April 2, 1980 to November 26, 1980 was found to be under other than honorable conditions, and was held to constitute a bar to VA benefits, exclusive of health care under 38 U.S.C. Chapter 17. See 38 U.S.C.A. §§ 101(2), 5303 (West 2002); 38 C.F.R. §§ 3.12, 3.13, 3.354 (2012). This matter is before the Board of Veterans' Appeals (Board) on appeal of a rating decision in February 2009 of a Department of Veterans Affairs (VA) Regional Office (RO) that denied service connection for a gastrointestinal disorder, claimed as ulcerative colitis, to include as secondary to a service-connected skin disorder (follicular occlusion with acne). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran is service-connected for a skin disorder (follicular occlusion with acne). He is also service-connected for scarring at the posterior neck line. The Veteran contends that he has a gastrointestinal disorder, claimed as ulcerative colitis, that is related to service, or, more specifically, that is related to his service-connected skin disorder. The Veteran specifically maintains that he has a gastrointestinal disorder, claimed ulcerative colitis, as a result of medications he has taken for his service-connected skin disorder. He reports that he has taken antibiotics, including Accutane and Bactrim, and that those medications either caused, or worsened, his gastrointestinal disorder, claimed as ulcerative colitis. The Veteran's available service treatment records for his period of honorable active duty for training in the Army Reserve from September 1975 to February 1976, as well as period of honorable service from April 2, 1976 to April 1, 1980, show treatment for skin problems. Post-service VA treatment records indicate that the Veteran was treated for numerous disorders, including variously diagnosed gastrointestinal disorders such as ulcerative colitis. The Veteran was also treated for his service-connected skin disorder on numerous occasions. There are several examination reports of record that address the etiology of the Veteran's gastrointestinal disorder, claimed as ulcerative colitis. A December 2008 VA gastrointestinal examination report included a notation by the examiner that the Veteran's claim file was not available for review. The diagnosis was ulcerative colitis. The examiner reported that ulcerative colitis was an inflammatory bowel disease of uncertain etiology. The examiner stated that it has not been shown to be caused by long-term antibiotic use. The examiner commented that, therefore, it was less likely than not that the Veteran's ulcerative colitis had been caused by the antibiotics he had taken for his chronic dermatologic condition. The examiner indicated that the Veteran's c. difficle diarrhea was very likely caused by the antibiotics, but that such was a treatable condition (and unrelated to ulcerative colitis) which appeared to have been successfully treated with Vancomycin and would, itself, not be considered to be a permanent, chronic, ongoing condition. The examiner did not review the claim file, and did not specifically address whether the Veteran's service-connected skin disorder aggravated the Veteran's diagnosed ulcerative colitis. The examiner solely indicated that it was less likely than not that the Veteran's ulcerative colitis had been caused by the antibiotics he had taken for service-connected skin disorder. Additionally, the examiner did not provide any rationale for his opinion, other than ulcerative colitis had not been shown to be caused by the long-term use of antibiotics. A June 2010 VA gastrointestinal examination report noted that the Veteran's claim file had been reviewed. The diagnoses were ulcerative colitis, hidradenitis suppurativa, and acne. The examiner reported that the Veteran had been treated for hidradenitis suppurativa for quite some time and that on two occasions, he was treated with Accutane for that condition. It was noted that the Veteran had been made aware of that fact that Accutane sometimes caused ulcerative colitis and that he was now claiming service connection for ulcerative colitis because he was treated with Accutane recently on two occasions. The examiner reported that the timeline between treatment with Accutane and the development of ulcerative colitis was not clear and was subject to debate. The examiner stated that it was more important that the Veteran was service-connected for acne and that he was claiming service connection for ulcerative colitis based on his treatment for hidradenitis suppurativa, which was a different disease, and for which he was not service-connected. The examiner stated that the Veteran was treated with Accutane twenty-seven years earlier for acne, which could not have caused ulcerative colitis twenty-seven years later. The examiner indicated that the Veteran was claiming service connection on the basis of hidradenitis suppurativa having been recently treated with Accutane. The examiner commented that it was less likely as not that the service connection could be granted for treatment for hidradenitis suppurativa with Accutane based on service-connection for acne. The examiner stated that the issue of Accutane was discussed because Accutane was known to cause ulcerative colitis. The examiner stated that the other medications mentioned as the basis for the claim were Prednisone and Silvadene ointment used for external use, and that those two medications were not associated with the development of ulcerative colitis. The examiner reported that the Veteran was solely service-connected for acne, and not for hidradenitis suppurativa, which he maintained was a different disease. However, an August 2003 VA skin diseases examination report related diagnoses of hidradenitis suppurativa-flaring and stasis dermatitis. In a September 2003 addendum to the August 2003 VA skin diseases examination report, the examiner specifically indicated that the Veteran's hidradenitis suppurativa was indeed an element of follicular occlusion like acne conglobata or dissecting cellulitis. Additionally, the examiner, pursuant to the June 2010 VA gastrointestinal examination report, did not address whether the medication the Veteran's received for his service-connected skin disorder aggravated his gastrointestinal disorder, claimed as ulcerative colitis. Further, the examiner stated that Accutane was known to cause ulcerative colitis, which contradicts the statement by the examiner at the December 2008 VA gastrointestinal examination that ulcerative colitis had not been shown to be caused by the long-term use of antibiotics. The Veteran underwent a further VA gastrointestinal examination in June 2013. The diagnosis was ulcerative colitis. The examiner commented that after a careful review of the claim file, it was her opinion that the Veteran's ulcerative colitis was not at least as likely as not due to or aggravated by the Accutane he received in 2003 to 2004, or other non-antibiotic medication prescribed for acne and hidradenitis suppurativa as part of follicular occlusive disorder. The examiner stated that there was no notation of Accutane use in the military in the claim file. It was noted that the Veteran stated that he was taking Accutane in the 1980s, but that there was no record of that in the claim file. The VA examiner found that the Veteran's ulcerative colitis was not due to or aggravated by the Accutane he received in 2003 to 2004, or by other non-antibiotic medication prescribed for acne and hidradenitis suppurativa as part of follicular occlusive disorder. However, the Veteran maintains that his gastrointestinal disorder, claimed as ulcerative colitis, was caused, or aggravated by, the medication he received for his skin disorder, including antibiotics such as Accutane and Bactrim. The VA examiner addressed the use of Accutane, but she referred to other non-antibiotic medication, as opposed to antibiotic medication. There are VA treatment reports of record that refer to antibiotic medications possibly aggravating the Veteran's gastrointestinal disorder, claimed as ulcerative colitis. For example, a prior January 2009 VA treatment entry related an assessment of hidradenitis suppurativa, improved. The examiner stated that the Veteran could not take Accutane in the past due to severe xerosis and that he could not take antibiotics secondary to colitis. A July 2009 VA treatment entry noted that the Veteran reported that Bactrim made his colitis worse and that he could not take Accutane due to severe dryness. The assessment was hidradenitis suppurativa. In light of the problems with the opinions provided pursuant to the December 2008, June 2010, and June 2013 VA examination reports, the Board finds that the Veteran has not been afforded a VA examination with the opportunity to obtain a responsive etiological opinion, following a thorough review of the entire claim folder, as to his claim for service connection for a gastrointestinal disorder, claimed as ulcerative colitis, to include as secondary to a service-connected skin disorder. Such an examination must be accomplished on remand. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Prior to the examination, any outstanding records of pertinent medical treatment must be obtained and added to the record. Accordingly, the case is REMANDED for the following: 1. Ask the Veteran to identify all medical providers who have treated him for gastrointestinal problems, including ulcerative colitis, since August 2013. After receiving this information and any necessary releases, contact the named medical providers and obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain records, inform him of such, and advise him he may obtain and submit those records. 2. Schedule the Veteran for a VA examination by an appropriate medical professional to determine the nature and likely etiology of his claimed gastrointestinal disorder, claimed as ulcerative colitis, to include as secondary to a service-connected skin disorder. The entire claim file (i.e., the paper claim file and any medical records contained in VBMS, Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner. If the examiner does not have access to VBMS and Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claim file so they can be available to the examiner for review. The examiner must diagnose all current gastrointestinal disorders, including ulcerative colitis. Based on a review of the claim file, examination of the Veteran, and generally accepted medical principles, the examiner must provide a medical opinion, with adequate rationale, as to whether it is as at least as likely as not (a 50 percent or greater probability) that any currently diagnosed gastrointestinal disorders, to include ulcerative colitis, are related to and/or had their onset during his period of honorable active duty for training in the Army Reserve from September 1975 to February 1976, as well as period of honorable service from April 2, 1976 to April 1, 1980. The examiner must also opine as to whether the Veteran's service-connected skin disorder caused or aggravated any diagnosed gastrointestinal disorders, to include ulcerative colitis. The examiner is informed that the Veteran's service-connected skin disorder is follicular occlusion with acne, and that a VA examiner has found that hidradenitis suppurativa was indeed an element of follicular occlusion like acne conglobata or dissecting cellulitis. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that the requested opinions cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 3. Then readjudicate the appeal. If the benefit sought remains denied, issue a supplemental statement of the case and return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). _________________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2013).