Citation Nr: 1629166 Decision Date: 07/21/16 Archive Date: 08/01/16 DOCKET NO. 08-38 239 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for Crohn's disease. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Sherrard, Counsel INTRODUCTION The Veteran, who is the Appellant in this case, had active service from May 1966 to May 1968, including service in Vietnam. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a June 2007 rating decision by the above Department of Veterans Affairs (VA) Regional Office (RO). The Board has remanded this case several times. Most recently, the Board requested a VHA opinion. Having received an adequate opinion, the case is now appropriate for appellate review. FINDING OF FACT The Veteran's current Crohn's disease is etiologically related to his active service. CONCLUSION OF LAW Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for Crohn's disease have been met. 38 U.S.C.A. §§ 101, 1101, 1110, 5103(a), 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Service connection may be granted for disability which is the result of disease or injury incurred in or aggravated by service, particularly when such disorder is manifested while the individual is in service and remains as a chronic condition thereafter. Service connection may be granted for a disease which is diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. In this case, the Veteran contends that his current Crohn's disease began during active service or within one month of service separation. He has a long and complicated history of gastrointestinal problems. In July 1968, two months after service separation, he sought treatment at the Saginaw VA Medical Center for symptoms of fever, chills, nausea, and vomiting. An undated VA Medical Certificate that is presumed to be associated with the same July 1968 visit indicates that he also complained of abdominal distress. He was diagnosed with malaria. However, he contends that these symptoms were the first manifestation of his Crohn's disease. Several physicians have also suggested that the Veteran's gastrointestinal problems may be somehow related to the malaria or to parasitic infection he contracted during active service or to the symptoms he experienced in 1968. For instance, in July 1973, the Veteran was admitted to a private hospital for right lower quadrant abdominal pain present for a year, and his history of malaria was described in detail, presumably because the treating clinician felt it to be potentially relevant to his current gastrointestinal problems. A July 1973 pathology report indicates a diagnosis of granulomatous colitis involving the right colon with small bowel adherence to the cecum and mass formation, as well as Meckel's diverticulum. A right colectomy was performed, and the history of malaria was again noted on the operative report. In February 1985, the Veteran's primary care physician, Dr. S., noted that his right colon was removed in 1973 secondary to parasitic infection obtained while serving in Vietnam. A colon biopsy revealed minimal to mild inflammatory cell infiltrate, consistent with chronic colitis. Dr. S. continued to note in subsequent treatment notes that he believed the colitis was secondary to parasitic exposure in Vietnam. In December 1986, the Veteran was first diagnosed with Crohn's disease after being admitted to St. Luke's Hospital for an acute small bowel obstruction secondary to recurrent Crohn's disease. It was noted that he had a history of exposure in Vietnam with questionable parasitic infection. Multiple subsequent treatment notes also indicate that, although he was not officially diagnosed with Crohn's disease until 1986, he had experienced symptoms of Crohn's disease at least since 1973 when he underwent the colectomy. The Veteran has also submitted several excerpts from articles and books in support of his claim. One such excerpt states that patients with Crohn's disease can have symptoms for many years prior to the diagnosis, and that initial symptoms can be more vague than with ulcerative colitis. Another article discusses the causes of Crohn's disease, which includes microbes such as viruses and bacteria. VA obtained a medical opinion in November 2012 that has been deemed inadequate by the Board. The VA gastroenterologist stated that the Veteran's current Crohn's disease was not likely related to his PTSD or malaria treated immediately after service, noting that there was no documented treatment of Crohn's disease in the service treatment records and stating that his opinion was based on his review of the claims file, medical literature, and his medical experience and expertise. No citations to the literature referenced were provided, and there was no further rationale. The VA examiner reiterated the same opinion in March 2015. The Board obtained a VHA opinion in June 2016 from a gastroenterologist, who, after reviewing the Veteran's records, stated that it was clear that the Veteran had advanced Crohn's disease in July 1973, as demonstrated by the pathology report of the right colectomy. The doctor explained that it takes years for patients with Crohn's disease to develop advanced disease, such small bowel adherence, and mass formation as seen in the 1973 pathology report. He further stated that, by reviewing the records, it was impossible for him to answer with certainty the question of whether the Veteran's Crohn's disease manifested in June 1968 or earlier. While there remains some uncertainty as to the date of manifestation of the Veteran's Crohn's disease, in light of the documented advanced Crohn's disease in 1973 - just five years after service separation - and the multiple indications in the post-service treatment records that his Crohn's disease is associated with the gastrointestinal symptoms he experienced in 1968, the Board finds that the evidence is, at minimum, in equipoise regarding the question of whether the Veteran's current Crohn's disease is related to active service. As such, the benefit-of-the-doubt will be conferred in the Veteran's favor and his claim for service connection for Crohn's disease is granted. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Given the full grant of benefits sought on appeal, no conceivable prejudice to the Veteran could result from this decision; therefore, no discussion of compliance with the VCAA is necessary. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). ORDER Service connection for Crohn's disease is granted. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs