Citation Nr: 1301290 Decision Date: 01/11/13 Archive Date: 01/16/13 DOCKET NO. 05-41 427 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUE Entitlement to service connection for a disability manifested by stomach problems and blood in the stool, to include irritable bowel syndrome (IBS) and/or hemorrhoids, to include as due to an undiagnosed illness. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. B. Yantz, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from July 2000 to July 2004. This case is before the Board of Veterans' Appeals (Board) on remand from the United States Court of Appeals for Veterans Claims (Court). The case was originally before the Board on appeal from an April 2005 rating decision of the Cleveland, Ohio Department of Veterans Affairs (VA) Regional Office (RO). [The Veteran's claims file is now in the jurisdiction of the Denver, Colorado RO.] In a decision issued in October 2009, the Board upheld the RO's denial of service connection for IBS. The Veteran appealed that decision to the Court. In March 2011, the Court issued a memorandum decision that vacated the October 2009 Board decision and remanded the matter on appeal for readjudication consistent with the instructions outlined in the memorandum decision. Pursuant to the Court's March 2011 memorandum decision, in November 2011, the Board recharacterized the Veteran's claim as service connection for a disability manifested by stomach problems and blood in the stool, to include IBS and/or hemorrhoids, and remanded the matter for additional development. In June 2012, the Board again remanded the matter for additional development. The Board notes that it has reviewed both the Veteran's physical claims file and "Virtual VA" (VA's electronic data storage system) to ensure that the complete record is considered. At present there are no additional documents pertinent to this appeal in Virtual VA. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if action on his part is required. REMAND As a preliminary matter, the Board notes that the most recent VA treatment record associated with the record is dated in January 2009, and notes that the Veteran was to follow up in March 2009 for review of IBS symptoms. There is no evidence of record to indicate that he failed to show for such a follow-up. In fact, in March 2009he submitted a written authorization (VA Form 21-4142) to obtain treatment records for the conditions of "blood in stool, stomach hurt[s]" from his VA treatment provider (T. Vogel, FNP), and the Veteran noted that "at this time we are working on getting blood work and other things done to figure out what it is." Any relevant outstanding VA treatment records may have a bearing on the instant claim (and are constructively of record), and must be secured. Pursuant to the Board's June 2012 remand, the Veteran underwent a VA intestinal disorders examination in August 2012 by a physician who is Board Certified in internal medicine, gastroenterology, and hepatology. According to the Board's remand instructions, the examiner was asked to: (1) determine the medical diagnoses for any disabilities manifested by stomach problems and blood in the stool during the pendency of the claim (to include IBS and/or hemorrhoids); and (2) opine whether it is at least as likely as not (a 50 percent or better probability) that each such diagnosed disability is related to the Veteran's service, to include his ingestion of anti-malarial pills therein. [The Board notes that, in his review of the Veteran's medical history, the examiner made reference to the Veteran being "seen at Urgent Care in 2007 for acute diarrhea and blood on the tissue paper." As the records relating to this Urgent Care visit are not currently of record and may have a bearing on the instant claim, they must be secured.] The August 2012 examiner provided the Veteran diagnoses of: (1) rectal bleeding - anal fissure (not documented) suggested by Veteran's history; and (2) functional diarrhea since 2010 by Veteran's history. With regard to IBS, the examiner noted that there is insufficient clinical evidence to establish a diagnosis of IBS at any time. With regard to hemorrhoids, the examiner noted that the report of "rectal bleeding, probably hemorrhoids" in December 2005 was undocumented and that no examination was done upon which to base the diagnosis. The examiner opined that it is less likely than not that the Veteran had or has any significant gastrointestinal disorder related to military service. The examiner also noted that anti-malaria pills (malaria prophylaxis) do not cause hemorrhoids or anal fissure, and he opined that it is less likely than not that anti-malaria pills (malaria prophylaxis) cause irritable bowel. The examiner noted that the Veteran's current gastrointestinal symptom of persistent loose stools since 2010 is most consistent with functional diarrhea that is related to stress at times as well as to fried and fatty foods. The August 2012 examiner failed to clearly opine whether it is at least as likely as not (a 50 percent or better probability) that each diagnosed disability (rectal bleeding - anal fissure, and functional diarrhea) is related to the Veteran's service, to include his ingestion of anti-malarial pills therein. The examiner also failed to consider the Veteran's contentions that he has suffered from his current gastrointestinal symptoms since returning from Iraq in 2004 (and not just since 2010, as was suggested by the examiner's assessment of the Veteran's current functional diarrhea). Finally, as the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, an opinion should be obtained as to whether the Veteran's current symptoms are indicia of an undiagnosed illness manifested by gastrointestinal symptoms. [Gastrointestinal signs or symptoms may be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness. 38 C.F.R. § 3.317(b)(10).] A clarifying opinion is needed.. Accordingly, the case is REMANDED for the following: 1. The RO should ask the Veteran to identify the provider(s) of any additional (records of which are not already associated with the record) treatment or evaluation he has received for a disability manifested by stomach problems and blood in the stool, and to provide all releases necessary for VA to secure any private records of such treatment or evaluation. The RO should obtain complete records of all such treatment and evaluation from all sources identified, to specifically include all records pertaining to an Urgent Care visit in 2007 for acute diarrhea and blood on the tissue paper, any VA follow-up appointment for IBS symptoms in March 2009, and any VA blood work conducted around March 2009. The RO should also secure complete copies of the clinical records of all VA treatment the Veteran has received for his claimed disability since January 2009. If any records requested are unavailable, the reason must be explained for the record. 2. After the development sought in Instruction #1 is completed, the RO should return the claims file to the physician who conducted the August 2012 VA intestinal disorders examination. The examiner must review the entire claims file (including this remand), and specifically respond to each of the following: (1) Based on the evidence of record, is it at least as likely as not (a 50 percent or better probability) that the Veteran's current rectal bleeding - anal fissure is related to any incident of his military service, to include his ingestion of anti-malarial pills therein? The examiner is to specifically consider and address the Veteran's allegations of continuity of symptomatology since returning from Iraq in 2004. (2) Based on the evidence of record, is it at least as likely as not (a 50 percent or better probability) that the Veteran's current functional diarrhea is related to any incident of his military service, to include his ingestion of anti-malarial pills therein? The examiner is to specifically consider and address the Veteran's allegations of continuity of symptomatology since returning from Iraq in 2004. (3) Based on the evidence of record, is it at least as likely as not (a 50 percent or better probability) that the Veteran's current symptoms are indicators of an undiagnosed illness manifested by gastrointestinal symptoms? The examiner must explain the rationale for all opinions. If the examiner determines that further examination of the Veteran is necessary to provide any requested opinion, then such examination should be scheduled. If the previous examiner is no longer available, then a new examination should be conducted, and all requested opinions rendered, by another qualified examiner. 3. The RO should ensure that all of the development sought is completed, arrange for any further development suggested by additional evidence received, and then re-adjudicate the claim. If the benefit sought remains denied, the RO should issue an appropriate SSOC and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board. The purpose of this remand is to ensure that all necessary development is completed. The Veteran 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 or the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ GEORGE R. SENYK 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) (2012).