Citation Nr: 1632587 Decision Date: 08/17/16 Archive Date: 08/24/16 DOCKET NO. 12-09 941 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUE Entitlement to service connection for Crohn's disease. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD E. F. Brandau, Associate Counsel INTRODUCTION The Veteran has active duty service in the United States Marine Corps from July 1967 to August 1969, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2011 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND Regrettably a remand is necessary for further development of the issue. Service treatment records show no evidence of symptoms of, or treatment for Crohn's disease during service. There was no indication that the Veteran reported abdominal pain or digestive difficulties at separation from service. The Veteran has reported he suffered from dysentery during service after drinking from a stream in Vietnam. Medical records note the Veteran's history of undergoing a terminal ileum resection in September 1973 and a history of Crohn's disease since that time. A 1995 hospital report noted he did well following the 1973 surgery until the late 1980's when he began to develop perianal symptoms. Since that time he has undergone several surgeries. In September 2011 a VA examiner reviewed the Veteran's claims file and opined that his Crohn's disease was not caused by or the result of military service or any illness or event during military service. The VA examiner explained that the etiology of Crohn's disease was unknown with genetic predisposition playing a significant role, that the Veteran's Crohn's disease fit temporally and diagnostically with late-onset Crohn's disease affecting the distal small bowel and colon, and that it had its onset long after service. As the VA examiner indicated the Veteran's Crohn's disease was late-onset but evidence suggests surgery in 1973 when the Veteran was 25 years old, the Board finds that an additional medical opinion is necessary. Although some medical opinions have been submitted to support the claim, those opinions are speculative in nature. See Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009) (holding that a doctor's statement that a veteran's brain tumor "may well be" connected to Agent Orange exposure was speculative). In this regard, a letter from the Veteran's private treatment provider in April 2012 noted that it was theoretically possible given the sequence of events and lack of previous personal or family history of inflammatory bowel disease that the Veteran's herbicide exposure or exposure to enteric pathogens in service caused his disability. The same month, a physician submitted a letter indicating that he had reviewed the Veteran's treatment history and researched the etiology of inflammatory bowel disease. He indicated that he did not know the answer to the etiology question but indicated that there was no evidence to the contrary on the etiology of inflammatory bowel disease as being due to Agent Orange exposure. In April 2012 the Veteran's friend who works as a registered pharmacist indicated that it was easy to believe that there was the distinct possibility that the Veteran's Crohn's disease may have been caused by environmental factors while serving in Vietnam. The Board notes that in December 2013 the National Academy of Science (NAS) issued Veterans and Agent Orange: Update 2012 (Update 2012). NAS found inadequate or insufficient evidence to determine whether an association exists between herbicide exposure and gastrointestinal, metabolic, and digestive disorders. See 79 Fed. Reg. 20308 (Apr. 11, 2014). In a 2010 statement, the Veteran suggested that one possible cause for his Crohn's disease was posttraumatic stress. As he has since established service connection for posttraumatic stress disorder (PTSD), his contention is considered to be a claim for secondary service connection. Notice pursuant to the Veterans Claims Assistance Act (VCAA) concerning the evidence needed to substantiate a claim for service connection on a secondary basis should be provided. Accordingly, the case is REMANDED for the following actions: 1. Send the Veteran a VCAA notice letter addressing service connection for Crohn's disease on a secondary basis. 2. Then, send the claims file to a VA gastroenterologist for review to obtain additional opinions on the Veteran's claim for service connection for Crohn's disease. If a VA examination is deemed necessary to respond to the questions presented, one should be scheduled. After review of the claims file the examiner should respond to the following questions: a. Is it at least as likely as not (50 percent probability or greater) that the Veteran's Crohn's disease arose in service or is otherwise related to service, to include his report of experiencing dysentery after drinking water from a stream in Vietnam and his exposure to herbicides? Please explain why or why not. While the examiner is free to cite to studies by the National Institute of Health or any medical treatises in rendering the opinion, the examiner's rationale cannot rely solely on the fact that VA has not included Crohn's disease in the list of presumptive conditions. In other words, the Board needs an opinion as to the likelihood that this Veteran's Crohn's disease, without regard to the conditions VA recognizes as being due to Agent Orange, is nevertheless at least as likely as not related to his exposure to Agent Orange in Vietnam. The examiner should provide a rationale for the opinion provided b. If not related to service, is it at least as likely as not that the Veteran's Crohn's disease was caused by his PTSD? Please explain why or why not. c. If not caused by his PTSD, is it at least as likely as not that his Crohn's disease has been permanently worsened beyond normal progression (versus temporary exacerbation of symptoms) by his service connected PTSD. Please explain why or why not. If it is determined that PTSD does cause a permanent worsening of the Crohn's disease, the examiner should attempt to quantify the degree of worsening beyond baseline level of severity of Crohn's disease that is due to the PTSD. 3. After undertaking the development above and any additional development deemed necessary, the Veteran's claim should be readjudicated. If the benefit sought on appeal remains denied, the appellant and his representative should be furnished a supplemental statement of the case and be given an appropriate period to respond thereto before the case is returned to the Board, if in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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 2014). _________________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board 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) (2015).