Citation Nr: 1603901 Decision Date: 02/03/16 Archive Date: 02/11/16 DOCKET NO. 07-32 023 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUE Entitlement to service connection for a gastrointestinal disorder, to include as secondary to service-connected psychiatric disorder or secondary to medications prescribed for service-connected psychiatric disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The Veteran had active service from April 1967 to July 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating action of the Department of Veterans Affairs (VA), Regional Office (RO) in Lincoln, Nebraska that, in pertinent part, denied service connection for a gastrointestinal disorder, to include as secondary to service-connected paranoid schizophrenia. In an April 2009 decision, the Board, in pertinent part, denied the Veteran's claim for entitlement to service connection for a gastrointestinal disorder, to include as secondary to service-connected paranoid schizophrenia. The Veteran then appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a February 2011 Memorandum Decision, the Court vacated and remanded the Board's April 2009 decision as to the issue of entitlement to service connection for a gastrointestinal disorder, to include as secondary to service-connected paranoid schizophrenia. In a September 2011 the Board remanded the Veteran's claim for additional development. In January 2013 and March 2013, the Board referred the Veteran's claim for an advisory medical opinion. In September 2013, July 2014 and April 2015, the Board remanded the claim for additional development. This is the first time this claim has been before the undersigned. The Board apologizes for the delays in the full adjudication of this case. FINDING OF FACT A gastrointestinal disorder was not incurred during the Veteran's active duty service and is not proximately due to or the result of his service-connected psychiatric disorder or the medications taken for this disorder. CONCLUSION OF LAW The criteria for entitlement to service connection for a gastrointestinal disorder, to include as secondary to service-connected psychiatric disorder, have not been met. 38 U.S.C.A. §§ 1101, 1110 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Analysis Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service in the line of duty. 38 U.S.C.A. § 1110; 38 C.F.R. §3.303. Service connection nonetheless may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing entitlement to direct service connection generally requires: (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 an injury; and (3) competent and credible evidence of a relationship or correlation between the disease or injury in service and the currently claimed disability - which is the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability, which is proximately due to, or the result of a service-connected disease or injury shall be service-connected. 38 C.F.R. § 3.310. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id; See Libertine v. Brown, 9 Vet. App. 521, 522 (1996); Harder v. Brown, 5 Vet. App. 183, 18 (1993). The standard of proof to be applied in decisions on claims for Veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See also 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Veteran's primary assertion is that his gastrointestinal disorder is due to his service connected psychiatric disorder, paranoid schizophrenia, and/or the medications taken for this disorder, including risperidone, citalopram and alprazolam. The Board will also consider whether this disability is directly related to his military service. The service treatment records do not show any complaints or findings of gastrointestinal problems. Post-service, a number of medical opinions have been obtained in relation to the Veteran's claim. At a March 2007 VA examination, the examiner opined that the Veteran's complaints of gas, explosive diarrhea, and bleeding were not caused by or the result of medication used for the Veteran's service connected psychiatric disorder, schizophrenia. The examiner reasoned that the Physician Desk Reference (PDR) did not list the aforementioned complaints as side effects of citalopram or risperidone, medications used to treat the Veteran's schizophrenia. In a May 2007 addendum opinion, the examiner clarified that the Veteran could perhaps have irritable bowel syndrome (IBS); however, since the Veteran's diarrhea was intermittent despite the chronic use of medication for schizophrenia, there was little to support a correlation between the Veteran's medication use and aggravation of the IBS. The examiner also noted that VA outpatient treatment records dated in April 2007 showed the Veteran denied any side effects on his current medications. Additionally, the examiner opined that a gastrointestinal disorder was not caused by or the result of the schizophrenia. The examiner reasoned that medical literature did not show that schizophrenia causes gastrointestinal disorders. An October 2011 VA examination report notes a diagnosis of irritable bowel syndrome (IBS). After examining the Veteran, reviewing the claims file and reviewing pertinent medical literature, the examiner commented that it was less likely than not that the Veteran's current gastrointestinal disorder was due to or aggravated by the service-connected paranoid schizophrenia, or medications taken for the paranoid schizophrenia. In providing this opinion, the examiner noted that with regard to risperidone, although the PDR or other medical sources may list gastrointestinal problems as a potential side-effect of such medication, it was not necessarily the case that risperidone caused the Veteran a chronic or ongoing gastrointestinal disorder, as he had taken medication on a daily basis for a number of years but only described periodic symptoms of once per week. The examiner further noted the Veteran's report that changes in his diet helped him to greatly reduce and control his gastrointestinal symptomatology. Moreover, the examiner commented in relation to potential direct causation or aggravation of IBS by schizophrenia that there is no evidence to suggest that schizophrenia results in IBS or episodic loose stools or diarrhea. In a January 2013 VA opinion, B.H., a gastroenterologist opined that while it was always possible that a medication could cause side effects, there was not a preponderance of evidence to support that the Veteran's gastrointestinal symptoms were likely the result of citalopram or risperidone. In a February 2013 addendum to the January 2013 VA opinion, B.H. opined that while it was always possible that a medication could cause side effects, there was no evidence to support the claim that the Veteran's gastrointestinal symptoms were more likely than not related to citalopram, risperidone, or alprazolam. In providing the opinion, B.H. noted that with respect to citalopram, three percent of patients experienced increased diarrhea over placebo, which means that only one in 33 additional patients developed drug-induced diarrhea as a result of taking this medication.. He further noted that citalopram had been studied as a possible treatment for irritable bowel syndrome, and had thereafter been used by physicians to treat such disease. Regarding risperidone, B.H. commented that gastrointestinal side effects appeared to be even less prevalent, and that upon examining patient self-reporting websites, he could not find evidence that more than two percent of patients self-reported that risperidone caused irritable bowel syndrome or diarrhea issues. Regarding alprazolam, B.H. noted that according to the package insert, patients taking such medication had less diarrhea and abdominal distress, which was consistent with his 21 years of clinical practice, as he could not recall any patients who reported gastrointestinal symptoms attributable to this medication. This finding provides more evidence against this claim. At a January 2014 VA medical examination, the examining physician determined that the Veteran did not have a current intestinal condition. The Veteran reported that the last time he had had problems with his bowels was the previous night, when he had experienced diarrhea. He indicated that he did not take any medication for his diarrhea, had never been to the emergency room for the diarrhea and could not remember the last time he was evaluated by a medical professional for the problem. He also indicated that the problem was better than it used to be. Additionally, the Veteran reported that he had had a colonoscopy eight years previously, where no pathology was found. Further, the Veteran reported that he had begun having stomach problems while working in a freezer at Swan's ice cream. He noted that he was eating a lot of spicy food at that time, along with food that was getting thrown away but was still edible, and that at that time, he was experiencing fecal urgency. He reported that he was no longer following this sort of diet. The examiner found that the Veteran's gastrointestinal symptomatology currently had no impact on his ability to work and concluded that no chronic disabling gastrointestinal disorder was present. In a November 2015 supplemental opinion, the January 2014 VA examiner reiterated the normal colonoscopy 8 years previously and the Veteran's reports that he had begun having problems with his stomach or bowels when he was working in a freezer at Swan's ice cream; that he was eating a lot of spicy food at that time, along with food that was getting thrown away but was still edible; that he no longer follows this type of diet; and that his diarrhea had improved. As a result, the examiner concluded that it was less likely than not that any current gastrointestinal disorder had its onset in service or is otherwise related to service. Similarly, the examiner concluded that it was less likely than not that the medications prescribed for the Veteran's service-connected psychiatric disorder (i.e. citalopram, risperidone and alprazolam) had caused or aggravated any current gastrointestinal disability, as the evidence supported a finding that the gastrointestinal disorder was due a regular diet of Swan's products, including potentially expiring food. In sum, the above summarized evidence shows that the only underlying gastrointestinal disability that has been diagnosed is irritable bowel syndrome (IBS), which is reasonably shown to have been present during a portion of the appeal period. However, the service treatment records do not show any findings or complaints of gastrointestinal symptomatology and the IBS was not diagnosed until many years after service. Additionally, the January 2014 VA examiner, in his November 2015 supplemental opinion, specifically found that it was less likely than not that any gastrointestinal disability had its onset in service or was otherwise related to service, based on the Veteran's affirmative report that the problem had become manifest in conjunction with the poor diet he followed much more recently while working at Swan's and the normal colonoscopy performed approximately 8 years prior to the January 2014 VA examination. There is no medical opinion of record to the contrary (i.e. an opinion tending to indicate that any current gastrointestinal disability is related to service). Similarly, the medical opinion evidence weighs against a finding that any current gastrointestinal disability has been caused or aggravated by the medications the Veteran takes for his service-connected psychiatric disability. In this regard, the March 2007 VA examiner, in the May 2007 addendum, specifically found that because the Veteran's diarrhea was intermittent despite the chronic use of medication for schizophrenia, there was little to support a correlation between the Veteran's medication use and aggravation of the IBS. Similarly, the October 2011 VA examiner found that it was less likely than not that the Veteran's current gastrointestinal disorder was due to or aggravated by the medications taken for the service-connected paranoid schizophrenia based on this same reasoning; the Veteran had taken medication on a daily basis for a number of years but only described gastrointestinal symptoms once per week. Further in the January 2013 and February 2013 opinions, B.H. noted that the likelihood that any individual patient would experience gastrointestinal side effects as a result of taking citalopram, risperidone and/or alprazolam was quite low. Moreover, the January 2014 VA examiner, in his November 2015 supplemental medical opinion, also found that it was less likely than not that the medications caused or aggravated any gastrointestinal disorder, finding that this disorder, which had been found present during the appeal period, but not during the VA examiner's January 2014 VA examination, was specifically attributed to the poor diet that the Veteran had previously followed. There is no medical opinion of record to the contrary (i.e. an opinion tending to indicate that any current gastrointestinal disability has been caused or aggravated by any of these medications). Finally, the medical opinion evidence specifically weighs against a finding that the Veteran's service-connected schizophrenia has directly caused or aggravated any current gastrointestinal disability. In this regard, after examining the Veteran, reviewing the claims file and reviewing pertinent medical literature, the October 2011 VA examiner specifically concluded that it was less likely than not that the Veteran's current gastrointestinal disorder was either due to or aggravated by the service-connected paranoid schizophrenia, noting that there is no evidence to suggest that schizophrenia results in IBS or episodic loose stools or diarrhea. As the examiner specifically addressed the likelihood that the current gastrointestinal disorder was either due to the schizophrenia or aggravated by the schizophrenia, and as he provided a specific, reasoned rationale based on the a review of the record and pertinent medical literature, the Board finds that his opinion adequately addressed both potential causation of gastrointestinal disability and potential aggravation of gastrointestinal disability. In this regard, this case is distinguishable from El Amin v. Shinseki, where it was unclear whether a VA examiner's opinion encompassed a theory of aggravation. 26 Vet. App. 136, 140 (2013). Additionally, there is no medical opinion of record to the contrary (i.e. an opinion tending to indicate that any current gastrointestinal disability has been directly caused by or aggravated by the Veteran's service-connected psychiatric disability). It is important for the Veteran to understand that there is against evidence in this case no against this claim. Although the Veteran has asserted that he has a current gastrointestinal disability caused or aggravated by the medications he takes for schizophrenia and may also believe that he has a current gastrointestinal disability directly caused by service or directly caused or aggravated by the service-connected schizophrenia, as he is a layperson, with no specific, demonstrated expertise concerning the etiology of gastrointestinal disability, such assertions and beliefs may not be afforded more than minimal probative value. See e.g. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Accordingly, as gastrointestinal disability was not shown in service or for many years thereafter and is not shown to have been caused or aggravated by the Veteran's service-connected psychiatric disorder or the medications he takes for this disorder, the preponderance of the evidence is against this claim and it must be denied. 38 C.F.R. §§ 3.303, 3.310; Shedden, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Alemany, 9 Vet. App. 518 (1996). Due Process VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See e.g. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159; Dingess v. Nicholson, 19 Vet. App. 473 (2006). In this case, VA provided adequate notice in a letter sent to the Veteran in December 2006. VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement relevant treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The service treatment records and post-service VA medical records are associated with the claims file. VA has also provided the Veteran with a number of medical examinations in this case with accompanying medical opinions, which are adequate to address the theories of entitlement raised. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this regard, the Board is cognizant of the Court's February 2011 finding that the initial March 2007 VA examiner's opinion was inadequate in addressing the likelihood that the Veteran's gastrointestinal disorder was caused or aggravated by his psychiatric medications as the examiner incorrectly indicated that the Physician Desk Reference (PDR) did not list the gastrointestinal complaints as side effects of citalopram or risperidone. The subsequent medical opinions of record ameliorate this deficiency and this mistaken finding by the March 2007 VA examiner is not being relied upon to support the instant decision. There is no indication of additional existing evidence that is necessary for a fair adjudication of the claim that is the subject of this appeal. Moreover, the Board notes that subsequent to the February 2011 Court decision, in a May 2012 rating decision, the Veteran was awarded a100 percent, maximum rating for his service-connected schizophrenia. Hence, beyond the notice and examinations provided, further notice or assistance to the Veteran is required to fulfill VA's duty to assist and further development is unlikely to serve any useful purpose. ORDER Service connection for a gastrointestinal disorder, to include as secondary to service-connected paranoid schizophrenia, or secondary to medications prescribed for service-connected paranoid schizophrenia, is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs