Citation Nr: 1122104	
Decision Date: 06/08/11    Archive Date: 06/20/11

DOCKET NO.  07-00 302A	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas


THE ISSUE

Entitlement to service connection for Crohn's disease.


REPRESENTATION

Veteran represented by:	The American Legion


ATTORNEY FOR THE BOARD

Cheryl E. Handy, Associate Counsel







INTRODUCTION

The Veteran, who is the appellant, served on active duty from March 2001 to June 2001.

This matter is before the Board of Veterans' Appeals (Board) on appeal of a rating decision in February 2006 of a Department of Veterans Affairs (VA) Regional Office (RO).

In January 2011, the Board sought an advisory medical opinion from the Veterans Health Administration (VHA) on the questions of whether Crohn's disease was incurred in or aggravated by service or whether Crohn's disease was caused by or aggravated by service-connected migraine headaches.  The VHA opinion was received in March 2011 and a copy of the opinion was furnished to the Veteran and her representative.  In May 2011, the Veteran submitted additional evidence.


FINDING OF FACT

Crohn's disease had onset in service.


CONCLUSION OF LAW

Crohn's disease was incurred in service.  38 U.S.C.A. §§ 1110, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. § 3.303 (2010).

The Veterans Claims Assistance Act of 2000 (VCAA)

The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim.  The VCAA applies to the instant claim.  

As service connection for Crohn's disease is granted, further discussion of VCAA compliance is not necessary. 


REASONS AND BASES FOR FINDING AND CONCLUSION

Principles of Service Connection

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service.  38 U.S.C.A. § 1110. 

Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service.  This may be accomplished by affirmatively showing inception or aggravation during service.  38 C.F.R. § 3.303(a).

The showing of a chronic disease in service requires a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic."  Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b).

Service connection may also 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). 

Evidentiary Standards

VA must give due consideration to all pertinent medical and lay evidence in a case where a Veteran is seeking service connection.  38 U.S.C.A. § 1154(a).  

Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience.  Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.  38 C.F.R. § 3.159.

Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion.  38 C.F.R. § 3.159.

The Board, as fact finder, must determine the probative value or weight of the admissible evidence.  Washington v. Nicholson, 19 Vet. App. 362, 369 (2005) (citing Elkins v. Gober, 229 F.3d 1369, 1377 (Fed. Cir. 2000) ("Fact-finding in veterans cases is to be done by the Board")). 

When there is an approximate balance of positive and negative admissible evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran.  38 U.S.C.A. § 5107(b). 

Facts

The service records shows that in March 2001, during about the first week of Officer Candidate School (OCS), the Veteran suffered a left ankle ligament injury.  Later in March 2001, she complained of nausea, vomiting, a dry mouth, light headedness, and a cough, but not of diarrhea, and the assessment was acute viral gastroenteritis.  

In April 2001, the Veteran complained of headaches, dizziness, vomiting, and photophobia, but not of diarrhea. She stated that her headaches began when she fell and hit the back of her head.  The assessments were possible migraine and gastroenteritis, probably related to medications.  




On a neurological consultation in May 2001, the Veteran was evaluated for persistent, intermittent headaches associated with nausea, vomiting, and photophobia.  It was noted that the Veteran could not keep medications down for treatment of the headaches.  The assessment was a mixed pattern of migraine and tension headaches.  In June 2001, the Veteran was subsequently separated from service because she did not complete OCS. 

After service, private medical records show that in September 2002 history included reflux esophagitis, which began during the Veteran's senior year in college [before OCS].  Also, the Veteran had gained a great deal of weight after her ankle injury.  In January 2003, it was noted that the Veteran was having occasional bloody stools.  

VA records show that in September 2004 the Veteran had anemia and hemoglobin of 8 and she complained of a bloody stool.  The diagnoses included fatigue.  In December 2004, the Veteran complained of heartburn, nausea, diarrhea, bad breath, and bloody stools.  In May 2005, a small bowel study showed signs of Crohn's disease. 

In a statement in August 2006, Dr. S.L.B., a VA psychiatrist, expressed the opinion that Crohn's disease began in service, although it was not diagnosed until June 2005, because migraine headaches often accompany a diagnosis of Crohn's disease. 

In a statement in August 2006, Dr. J.B., a VA neurologist, stated that migraines and polyarthralgia can be complications of Crohn's disease and the fact that migraine headaches improved when steroids were prescribed for Crohn's disease was evidence of an etiological relationship between the two disabilities.  Dr. J.B. expressed the opinion that the Veteran's migraine headaches, for which service connection was in effect, were the result of Crohn's disease.

On VA examination in March 2008, the Veteran reported a history of nausea, vomiting with occasional bloody tinged-vomitus, and occasional diarrhea with bright red blood, but no constipation.  After a review of the Veteran's service treatment records and VA treatment records were reviewed.  

The VA examiner found no evidence of Crohn's disease in service with no manifestations of abdominal pain, fever, or bloody diarrhea.  The examiner observed that the hallmarks of Crohn's disease are fatigue, prolonged diarrhea with abdominal pain, weight loss, and fever, with or without gross bleeding, none of which were noted in the service treatment records.

In March 2011, the Board obtained a VHA expert medical opinion on the following questions:  

1). Whether it was more likely than not (probability greater than 50 percent), at least as likely as not (probability of 50 percent), less likely than not (probability less than 50 percent), or an opinion was not possible without resort to speculation that Crohn's disease had onset in service? 

2). If, Crohn's disease did not have onset in service, was Crohn's disease caused or aggravated by service-connected migraine headache?  

The VHA expert, a gastroenterologist, expressed the opinion that Crohn's disease did not have onset in service.  The VHA expert explained that the conditions the Veteran was treated for in service were a foot injury, an ankle sprain, and migraine or tension headaches, although she did have one episode of gastroenteritis.  The VHA expert stated that the onset of symptoms related to Crohn's disease was at the end of 2004 with the diagnosis being established in May or June of 2005.  In addition, the VHA expert noted that the pertinent medical literature did not reflect any connection between migraine and Crohn's disease. 

In response to the VHA expert's opinion, the Veteran submitted an opinion from another VA gastroenterologist.   The other VA gastroenterologist stated that the Veteran's records from her period of service had been reviewed, particularly the entries, showing nausea and vomiting, diarrhea in April 2001, and emergency room treatment for dehydration.  



The other VA gastroenterologist stated Crohn's disease primarily involves the small bowel and spares the colon, which would explain symptoms of recurrent nausea and vomiting instead of diarrhea as the primary symptoms in service, because colon was relatively functional.  The other VA gastroenterologist expressed the opinion that the recurrent upper gastrointestinal symptoms in service were more likely than not due to small bowel Crohn's disease.

Analysis

The Veteran has submitted evidence favorable to her claim, namely, the statement of a VA gastroenterologist, who expressed the opinion that the gastrointestinal symptoms manifested in service were attributable to Crohn's disease, although the diagnosis was not made until four years later.  The VA gastroenterologist noted that the location of the Veteran's ulcerative nodes in the small bowel meant that her condition was more likely to be manifested by nausea and vomiting than by bloody diarrhea, which was consistent with the symptoms manifest in service.  

The evidence against the claim consists of the report of VA examination in March 2008 and the opinion of a VHA expert, also a gastroenterologist.  The VA examiner based his negative opinion on the lack of abdominal pain and bloody diarrhea in service, and based his negative opinion on this fact.  The VHA expert also noted that the Veteran's symptoms in service were more concentrated in the upper gastrointestinal region, implying that the negated the possibility of any relationship to the post-service diagnosis of Crohn's disease.

With regard to medical opinions, the probative value or evidentiary weight to be attached to a medical opinion is within the Board's province as finder of fact. The guiding factors in evaluating the probative value of a medical opinion include whether the opinion is based upon sufficient facts, and whether the opinion applied valid medical analysis to the significant facts of the case in order to reach the conclusion submitted in the opinion.  Nieves-Rodriguez, 22 Vet. App. 295, 304 (2008).

When, after careful consideration of the entire record, a reasonable doubt arises regarding service origin, such doubt will be resolved in favor of the Veteran.  By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim.  38 C.F.R. § 3.102.

In this case, where the significant facts are not disputed and the same set of facts have resulted in contradictory conclusions, the Board finds that there is an approximate balance of positive and negative evidence, which does not satisfactorily prove or disprove the claim of service connection.  Under these circumstances, as there is a reasonable doubt, which is resolved in the Veteran's favor, service connection for Crohn's disease is established on the theory that service connection may be granted for a disease first diagnosed after service 
when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).


ORDER

Service connection for Crohn's disease is granted.



____________________________________________
George E. Guido Jr.
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs