Citation Nr: 1318367 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 09-17 544 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for irritable bowel syndrome (IBS). 2. Entitlement to service connection for a disability manifested by acid reflux, polyps in the throat and esophagus, bacteria, and a hole in the stomach (gastroesophageal condition), to include as due to an undiagnosed illness. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL The Veteran and spouse ATTORNEY FOR THE BOARD Adrian Jackson, Counsel INTRODUCTION The Veteran served on active duty from August 1979 to March 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 2007 and March 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The October 2007 decision denied service connection for a gastroesophageal condition. The March 2009 decision reopened and denied the claim for service connection for IBS. In support of his claims, the Veteran and his spouse testified at a hearing at the RO in December 2008 on the issue of service connection for a disability manifested by acid reflux, polyps in the throat and esophagus, bacteria, and a hole in the stomach (gastroesophageal condition), to include as due to an undiagnosed illness; the Veteran did not request a hearing on the issue of service connection for IBS. In January 2013, the Board also reopened the claim for service connection for IBS and remanded the issues of service connection for IBS and a gastroesophageal condition to obtain examination and opinion. The case has been returned for review. However, because all of the development directed by the prior remand has not been completed, the Board in turn is remanding the claim for service connection for a disability manifested by acid reflux, polyps in the throat and esophagus, bacteria, and a hole in the stomach (gastroesophageal condition), to include as due to an undiagnosed illness, to the RO via the Appeals Management Center (AMC) in Washington, DC. See Stegall v. West, 11 Vet. App. 268 (1998). FINDING OF FACT The most credible and competent evidence indicates that the Veteran does not have IBS. CONCLUSION OF LAW The Veteran does not have IBS due to disease or injury incurred in or aggravated by his active military service nor may it be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. The Duties to Notify and Assist Before addressing the underlying merits of a claim, the Board generally is required to ensure that VA's duties to notify and assist the claimant with the claim have been satisfied under the Veterans Claims Assistance Act (VCAA). 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record: (1) that is necessary to substantiate the claim; (2) that VA will obtain and assist the claimant in obtaining; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). These notice requirements apply to all elements of a service-connection claim, including the "downstream" disability rating and effective date elements. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). In this case, letters satisfying these notice requirements of 38 C.F.R. § 3.159(b)(1) were sent to the Veteran in May 2007 and February 2009. The letters informed him of the evidence required to substantiate his claims and of his and VA's respective responsibilities in obtaining this supporting evidence. The letters also complied with Dingess by as well discussing the "downstream" disability rating and effective date elements of the claim. Further, there is no allegation or evidence of any content or timing error in the provision of the VCAA notice he received. So absent this pleading or showing, the duty to notify has been satisfied. VA also has satisfied its duty to assist the Veteran with this claim by obtaining all potentially relevant evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO and AMC have obtained all records that he has identified as possibly pertinent, including his service treatment records (STRs) and post-service VA and private medical evaluation and treatment records. The Board also, remanded this claim to obtain a medical nexus opinion concerning the determinative issue of the etiology of his claimed disability, and specifically insofar as the likelihood it is directly or presumptively related to his military service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The VA compensation examiner designated to provide the medical nexus opinion responded in February and March 2013 examination reports with her findings, and her opinion is responsive to this determinative issue of causation, so, as already mentioned, there was compliance with this remand directive. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Chest v. Peake, 283 Fed. App. 814 (Fed. Cir. 2008); and Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Thus, the duty to assist the Veteran with this claim also has been satisfied. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. II. General Statutes, Regulations and Precedent Cases Governing Claims for Service Connection Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be established either by showing direct incurrence or aggravation in service or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). The Board notes the Veteran's military service coincides in part with the Persian Gulf War and his military records confirm his overseas service in Southwest Asia. He is in receipt in pertinent part of a Combat Infantryman Badge, Kuwait Liberation Medal, and Southwest Asia Service Medal with two Bronze Stars. A presumption exists for veterans who serve in the Persian Gulf, such as the case here, who exhibit objective indications of a qualifying chronic disability if that disability (a) 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 (b) by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317 (2012). The signs or symptoms covered under this presumption include those affecting the gastrointestinal system. See 38 C.F.R. § 3.317 (b). For purposes of 38 C.F.R. § 3.317, a qualifying chronic disability means a chronic disability resulting from any of the following (or combination of the following): (A) An undiagnosed illness; (B) a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as: (1) Chronic fatigue syndrome; (2) Fibromyalgia, (3) Functional gastrointestinal disorders (excluding structural gastrointestinal diseases), including irritable bowel syndrome. 38 C.F.R. § 3.317(a)(i). "Functional gastrointestinal disorders" are a group of conditions characterized by chronic or recurrent symptoms that are unexplained by any structural, endoscopic, laboratory, or other objective signs of injury or disease and may be related to any part of the gastrointestinal tract. Specific functional gastrointestinal disorders include, but are not limited to, irritable bowel syndrome, functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, and function dysphagia. These disorders are commonly characterized by symptoms including abdominal pain, substernal burning or pain, nausea, vomiting, altered bowel habits (including diarrhea, constipation), indigestion, bloating, postprandial fullness, and painful or difficulty swallowing. Diagnosis of specific functional gastrointestinal disorders is made in accordance with established medical principles, which generally require symptom onset at least 6 months prior to diagnosis and the presence of symptoms sufficient to diagnose the specific disorder at least 3 months prior to diagnosis. Id. The term "medically unexplained chronic multisymptom 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 multisymptom illnesses of partially understood etiology and pathophysiology are not considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). "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)(3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or 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; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period are considered chronic. The 6-month period of chronicity is 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)(4). In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117, 38 C.F.R. § 3.117, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. There are currently no diagnosed illnesses that have been determined by the Secretary to warrant a presumption of service connection under 38 C.F.R. § 3.317(a)(2)(C). Lastly, compensation shall not be paid under section 3.317 if there is affirmative evidence that an undiagnosed illness was not incurred during active military service in the Southwest Asia theater of operations during the Persian Gulf War; 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). To establish entitlement to direct service connection, there must be: (1) competent and credible evidence confirming the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of his claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002). Disorders diagnosed after discharge may still be service connected if all the evidence, including pertinent service records, establishes the disorder was incurred in service. 38 C.F.R. § 3.303(d). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). 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 the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). VA is to give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. 38 U.S.C.A. § 1154(a). The United States Court of Appeals for the Federal Circuit (Federal Circuit) held that medical evidence is not always or categorically required in every instance to establish the required nexus or linkage between the claimed disability and the Veteran's military service. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Citing its previous decisions in Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) and Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the Federal Circuit stated in Davidson that it has previously and explicitly rejected the view that competent medical evidence is always required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. See Id. at 1316. Instead, under 38 U.S.C.A. §§ 1154(a) lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau, 492 F.3d at 1377 (footnote omitted). For example, a layperson would be competent to identify a "simple" condition like a broken leg, but would not be competent to identify a form of cancer. Id. at 1377. Thus, when considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). The determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record, medical and lay, and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 C.F.R. § 3.102. III. Service Connection for IBS The Veteran's STRs show that in January 1980, the Veteran complained of stomach cramps and diarrhea; he was treated with Kaopectate. The diagnostic impression was upset stomach. He was also treated in with Kaopectate in April 1987 for diarrhea. In September 1988, he complained of vomiting and diarrhea. The assessment was diarrhea. He was prescribed Kaolin and told to return if symptoms persisted. In October 1990, he reported that he was sick to his stomach. He also complained of muscle aches, chills, and vomiting. The diagnosis was viral syndrome. Private medical records show that beginning in April 1998, the Veteran complained of a 1-month history of an itchy throat. The initial diagnosis was pharyngitis. In May 1998, he continued his complaints of a sore throat. This time he reported a six month history of throat problems. Eventually in December 1998, gastroesophageal reflux disease (GERD) was diagnosed. In March 1999, an esophagogastroduodenoscopy (EGD) with biopsy was performed. In May 1999, hiatal hernia, umbilical hernia, and esophageal reflux with esophagitis were diagnosed. He underwent laparoscopic fundoplication, crural repair, esophagogastroduodenoscopy, and repair of umbilical hernia. In January 2007, the Veteran sought to establish care at VA. During the initial examination he reported his history of laparoscopic fundoplication. In response to inquiry, he indicated that he had no history of altered appetite or bowel habits, pain, weight loss, jaundice, melena, or hematochezia. At the DRO hearing in December 2008, the Veteran reported his in-service history mentioning that he exposed to chemicals and uranium during the Persian Gulf War. He indicated that he was given pills which affected him and raised the issue of IBS. His spouse testified that she and the Veteran first met in 1998 and married in 1999, seven years after his separation from service. A VA examination was conducted in January 2009. The diagnosis was history of GERD status post surgical correction, resolved without significant residuals; as to IBS, the examiner stated that there was no IBS as there was no significant pathology. VA outpatient records show that in March 2009, the Veteran requested a colonoscopy for IBS. When seen in April 2009, the Veteran reported a 2-year history of abdominal cramping and diarrhea. A colonoscopy was performed in May 2009. There were polyps found in the proximal ascending colon and recto-sigmoid colon which were resected. He also had internal hemorrhoids and diverticulosis in the sigmoid colon. Another VA examination was conducted in July 2010. The Veteran reported his symptoms and indicated that he had blood in his bowels. He also stated that his primary care provider sent him for a colonoscopy. He continued to have 3-4 bowel movements daily that alternated between diarrhea and hard stools. The examiner diagnosed IBS. In June 2012, the Veteran stated that he began to experience bowel problems in 1990 when he was serving near Kuwait City. He stated that his problems have persisted since that time. Also in June 2012, the Veteran's spouse, stated that he has had gastrointestinal symptoms daily since they were married. He had to change his diet and take medication to manage his symptoms. In light of the Veteran's reported history, as noted, the Board remanded the case in January 2013. A VA examination was conducted the next month, and the VA examiner provided an addendum in March 2013. After reviewing the Veteran's medical history and examining him, the nurse reported that the Veteran's symptomatology was not in accordance with the Rome III criteria for IBS. This is a set of guidelines that outlines symptoms and applies parameters such as frequency and duration in order to diagnose IBS. In reaching her conclusions, she took into consideration the physical assessment, his medication profile, as well as the results of diagnostic testing that included colonoscopy and EGD. This examiner also noted that the Veteran had or had in the past a diagnosis of GERD but that the Veteran reported that he had not had any symptoms of GERD since his surgery. Objectively, the examiner noted that the Veteran did not have any signs or symptoms due to any esophageal condition including GERD. However, with respect to intestinal conditions, the examiner did note that the Veteran did have signs or symptoms of such manifested by diarrhea. As explained, the most fundamental requirement for any claim for service connection is that the Veteran must have proof he has the condition claimed. See Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328 (1997) (indicating VA compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability); see, too, McClain v. Nicholson, 21 Vet. App. 319 (2007) (further clarifying that this requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). Congress has specifically limited entitlement for service-connected disease or injury to cases where such incidents have resulted in disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998). A current disability means a disability shown by competent medical evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). In this regard, a review of his STRs, does show that he complained of and received treatment for stomach problems on different occasions during service and he also received post-service treatment for various gastrointestinal complaints that for the most part has been diagnosed in conjunction with GERD. The Board notes that he is competent, even as a layman, to proclaim for example having experienced gastrointestinal problems. But his lay testimony concerning this also must be credible to ultimately have probative value. See Rucker v. Brown, 10 Vet. App. 67 (1997) and Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). In this case, the Board finds that the Veteran is not competent from a medical point of view to challenge the medical professional conclusion that the symptoms that the Veteran has complained of having since service are symptoms of IBS. See Struck v. Brown, 9 Vet. App. 145 (1996) (discussing how contemporaneous medical findings may be given more probative weight than contrary evidence offered years later, long after the fact); Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor); Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding a Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the Veteran wrote during treatment than to his subsequent assertion years later). In this case, his statements are not sufficient competent evidence to establish that his gastrointestinal condition is IBS. It is not shown that he has the medical expertise to make diagnoses and supply opinions concerning the relationship between his current gastrointestinal complaints during and following service and a current gastrointestinal diagnosis. For these reasons and bases, the Board rejects the Veteran's unsubstantiated lay statements as competent and credible evidence sufficient to establish that his gastrointestinal condition is a result of IBS or that it is related to his military service. See Colantino v. Shinseki, No. 2009-7067, 2010 WL 2163002 (Fed. Cir. June 1, 2010); Johnson v. Shinseki, No. 2010-7060 (Fed. Cir. June 10, 2010). It is noted that VA examiners in July 2010 diagnosed IBS. However, this opinion was inadequate and one of the reasons for the prior remand. This nurse (and the concurring physician) did not provide any rationale for the opinion, and this is where most of the probative value of the opinion is derived. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (indicating "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion."). See also Bloom v. West, 12 Vet. App. 185, 187 (1999); Black v. Brown, 5 Vet. App. 177, 180 (1995) (a medical opinion is inadequate when unsupported by clinical evidence). Absent sufficient articulation of the underlying rationale, the Board is not compelled to accept a physician's opinion, regardless of whether it is unfavorable or favorable to the claim. See Wilson v. Derwinski, 2 Vet. App. 614 (1992). Consequently, the Board finds that the preponderance of the evidence is against this claim and, as such, it must be denied. 38 C.F.R. § 3.102 (2009); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). ORDER Service connection for IBS is denied. REMAND As noted in the prior remand, the Veteran also contends that he is entitled to service connection for a disability manifested by acid reflux, polyps in the throat and esophagus, bacteria, and a hole in the stomach (gastroesophageal condition), to include as due to an undiagnosed illness. In the prior remand, the Board noted that the July 2010 VA examiner stated that the Veteran had a history of GERD, status post-surgical correction, which resolved without evidence of significant residuals. However, the Board also pointed out that the examiner did not address the Veteran's other symptoms, including an alleged hole in his stomach. Further, this examiner did not provide an etiology opinion for the Veteran's GERD. Nor, did he address the Veteran's assertion of continuity of symptoms. Therefore, the Board requested additional medical commentary. As noted above, another VA examination was conducted in February 2013 and the examiner also provided an addendum in March 2013. While she addressed some questions posed by the Board, (including whether he had IBS and an explanation concerning the Veteran's comments regarding a hole in his stomach) she did not adequately address all questions. Specifically, she did not address the Veteran's and his spouse's assertions that his symptoms began in service and have persisted since then. Further, she did not provide an explanation for the Veteran's report and her notation that the Veteran had diarrhea that was sometimes explosive and unrelated to specific foods alternating with normal bowel movements. More importantly, while she indicated that he had a history of GERD and no current esophageal condition, she did not identify the source or etiology of his current intestinal symptoms including recurrent diarrhea. At his December 2008 hearing the Veteran admitted that he no longer had reflux or throat problems such as hoarseness since his 1999 surgery. He stated that he had 3-4 bowel movements per day. The VA examiner in January 2009 also indicated in the diagnosis that the Veteran has a history of GERD without significant residuals. However, the VA examiner did not identify any residuals, significant or not. When seen by VA in April 2009, the Veteran reported a 2-year history of abdominal cramping and diarrhea. A colonoscopy was performed in May 2009. There were polyps found in the proximal ascending colon and recto-sigmoid colon which were resected. He also had internal hemorrhoids and diverticulosis in the sigmoid colon. VA outpatient records dated in December 2009 show that the Veteran complained of abdominal cramping and diarrhea. In fact, he was prescribed Dicyclomine for the reported gastrointestinal symptoms. Another VA examination was conducted in July 2010. The Veteran reported his symptoms and indicated that he had blood in his bowels. As noted, the VA examiner in July 2010 diagnosed IBS, but this diagnosis was ruled out by the most recent VA examination in March 2013. While the VA examiner in 2013 ruled out IBS, she failed to comment on his current complaints, to include whether they are part of an undiagnosed illness, or residuals from his GERD, or a separate gastrointestinal disorder. Consequently, this medical opinion is inadequate because it fails to comply with the Board's prior remand directive. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). Therefore, further comments are needed. Accordingly, the case is REMANDED for the following action: 1. If still available, forward the claims file to the February 2013 VA compensation examiner to have this examiner provide supplemental comment regarding the Veteran's current symptoms (whether related to GERD or not). She must identify all current gastrointestinal symptoms and/or diagnoses. Then she must determine specifically, whether any current symptoms or diagnosed disorder is related to his military service and/or is part of an undiagnosed illness or chronic multi-symptom illness due to service in the Gulf War. Specifically, please respond to the following: Based on the prior physical examination and comprehensive review of the claims file, please evaluate this Veteran with Southwest Asia service for any chronic disability pattern. The Veteran has claimed a disability pattern related to gastrointestinal problems. Please provide a medical statement explaining whether the Veteran's disability pattern is: (1) an undiagnosed illness, (2) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (3) a diagnosable chronic multisymptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis. If, after examining the Veteran and reviewing the claims file, the examiner determines that the Veteran's disability pattern is either (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis, then please provide a medical opinion, with supporting rational, as to whether it is "at least as likely as not" (50 percent or more probable) that the disability pattern or diagnosed disease for gastrointestinal problems is related to a specific exposure event experienced by the Veteran during service in Southwest Asia or otherwise to service. In making these necessary determinations, the examiner must consider the Veteran's and his spouse's lay statements regarding having experienced relevant symptoms including chronic diarrhea, while in service and on a continuous basis during the many years since. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination found inadequate because the examiner did not comment on Veteran's report of in-service injury and, instead, relied on lack of evidence in the service treatment records to provide negative opinion). If, for whatever reason, it is not possible or feasible to have this same VA examiner provide this further comment, then have another equally qualified examiner provide this necessary additional medical opinion. In this eventuality, it may be necessary to have the Veteran reexamined, but this is left to the designee's discretion as to whether another examination is needed to make this determination of causation. Whoever is designated to provide this additional comment must discuss the rationale of the opinion, whether favorable or unfavorable, if necessary citing to specific evidence in the file. To facilitate providing this additional comment, it is imperative the designated examiner review the claims file (or, in the case of the prior examiner, refamiliarize herself with the pertinent evidence in the claims file) for the relevant medical and other history. This review includes considering this remand and the Board's prior remand. 3. Upon completion of this additional development, readjudicate this claim in light of this additional evidence. If this claim is not granted to the Veteran's satisfaction, send him and his representative another supplemental statement of the case (SSOC) and give them an opportunity to submit additional evidence and/or argument in response before returning the file to the Board for further appellate consideration of this claim. The Veteran has the right to submit additional evidence and argument on the matter or matters 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. 2012). ______________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs