Citation Nr: 1758905 Decision Date: 12/19/17 Archive Date: 12/28/17 DOCKET NO. 10-12 385 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for hemorrhoids, to include as due to an undiagnosed illness, medically unexplained multisymptom illness, or service-connected disability. 2. Entitlement to service connection for irritable bowel syndrome (IBS), to include as due to an undiagnosed illness, medically unexplained multisymptom illness, or service-connected disability. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran and her husband ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel INTRODUCTION The Veteran served in the United States Navy reserves and had active duty from December 2006 to October 2007. She served in the Persian Gulf, specifically Iraq, from January 10, 2007, to September 23, 2007. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In October 2011, the Veteran and her spouse presented testimony during a Board videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the electronic claims file. In November 2012, July 2015, and December 2016, the Board remanded the claims for additional development. As the requested development was completed, the Board finds that there has been substantial compliance with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). This appeal was processed using the Veteran's Benefits Management System (VBMS) and Virtual VA paperless claims processing systems. Accordingly, any future consideration of the Veteran's case should take into consideration the existence of these electronic records. FINDINGS OF FACT 1. The Veteran's hemorrhoids are not due to an undiagnosed illness or medically unexplained multisymptom illness and were not incurred in service, are not otherwise related to service, and were not caused or aggravated by a service-connected disability. 2. The Veteran's gastrointestinal problems, to include IBS, are not due to an undiagnosed illness or medically unexplained multisymptom illness and were not incurred in service, are not otherwise related to service, and were not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. Entitlement to service connection for hemorrhoids is not warranted. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310, 3.317 (2017). 2. Entitlement to service connection for IBS or other gastrointestinal problems is not warranted. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310, 3.317 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist Neither the Veteran nor her representative has identified any shortcomings in fulfilling VA's duty to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). For the above reasons, the Board finds the duties to notify and assist have been met, all due process concerns have been satisfied, and the appeal may be considered on the merits. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That a disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Pre-deployment records document that the Veteran had no problems with hemorrhoids or IBS prior to her active service and deployment to Southwest Asia. During active service, in April 2007, the Veteran was treated for nausea, dry heaves, vomiting, diarrhea, and abdominal pain. She denied bloody stools at that time. It was somewhat unclear when the symptoms started, but she had been unable to eat for the previous 24 hours. The assessment was gastroenteritis. In a September 11, 2007, post-deployment health assessment shortly before her return from Southwest Asia, the Veteran reported diarrhea and vomiting during her deployment. Immediately following her return from Southwest Asia, however, the Veteran had a health assessment in which she explicitly denied any gastrointestinal symptoms. The following day, in a subsequent September 2007 post-deployment health assessment the Veteran denied diarrhea, frequent indigestion, or vomiting during her deployment, although the problem list did include a notation of gastroenteritis. In her original May 2008 claim, the Veteran reported that her hemorrhoids and IBS were not treated while on active duty. The Veteran underwent a VA general medical examination in July 2008. The examiner noted review of the claims file. The Veteran reported hemorrhoids that began in August 2007 after returning from Iraq. Since onset the hemorrhoids had been stable with fair response to treatment. On examination, there were noted external hemorrhoids, which was the examiner's ultimate diagnosis. The Veteran reported IBS that began during her deployment to Iraq. She described experiencing a lot of gas and frequent bowel movements when stressed. The Veteran also experienced bowel urges whenever she had to go to a meeting. Since onset the symptoms had been stable. The examiner diagnosed "Sounds like frequent bowel movements triggered by Stress" that was associated with IBS. In her March 2010 substantive appeal, the Veteran stated that she did not have problems with hemorrhoids prior to deployment, but that such problems "developed while deployed and while being recalled. The diagnosis and existence of this condition comes after deployment. I feel that this may be related [] to my MRE diet." As to the IBS, the Veteran acknowledged that the VA examination did not include a specific diagnosis of IBS, but indicated that her claim was "bowel problems (irritable) secondary to posttraumatic stress disorder to include anxiety and depression" and she felt that the VA examination report supported such findings. In support of her claim, the Veteran submitted a September 2011 letter from a private board certified internist that noted review of the Veteran's history, including the full medical records provided by the Veteran that included "a book binder full of documents related to multiple disabling conditions which may have military service related cause." The noted problems included irritable bowel resulting in hemorrhoids and bowel dysfunction. Following examination, the physician concluded that the Veteran's IBS was "related in part to her post-traumatic stress disorder." During her October 2011 Board hearing, the Veteran reiterated that she had not had problems with hemorrhoid prior to going on active duty and that while on active duty she began to experience bloody stools. She did not seek treatment at the time because it was not the type of problem that you got treatment for in Southwest Asia. She was unsure as to when she initially sought treatment for the hemorrhoids. The Veteran indicated that her medical treatment providers had told her that the hemorrhoids were related to her service-connected mental health problems. The Veteran also claimed that her IBS was secondary to her service-connected psychiatric disorder. She denied any IBS symptoms prior to entrance into active service and first realized that she was experiencing such symptoms, "After coming back [from Southwest Asia] and just dealing with life you know." Specifically, the Veteran indicated that she began experiencing IBS symptoms about 1.5 weeks after her return from Iraq. The Veteran was afforded a VA intestinal examination in March 2013. The examiner noted review of the claims file and the Veteran's reports of a diagnosis of IBS in about 2006. The Veteran reported that while stationed in Iraq in 2006 and 2007 she had an onset of diffuse abdominal discomfort associated with diarrhea. The symptoms came on when she became nervous or anxious. The symptoms were mild and associated with "gas" in the abdomen. The Veteran denied constipation or gastrointestinal bleeding. The Veteran reported that she saw a physician once while in Iraq who indicated that she might have IBS. Following examination, the examiner concluded that it was less likely than not that the Veteran's IBS symptoms had their onset during service. The rational noted the unavailability of treatment records during deployment, but that both prior and subsequent to deployment the Veteran denied gastrointestinal symptoms. The examiner could not reach an opinion without resort to speculation regarding causation or aggravation of the IBS symptoms due to the posttraumatic stress disorder, since the etiology of IBS and its relationship with psychiatric problems was not known. The Veteran was afforded a VA rectal examination in March 2013. The examiner noted review of the claims file and a diagnosis of internal or external hemorrhoids. The Veteran reported onset of hemorrhoids in January 2007 while stationed in Iraq. The hemorrhoid discomfort had continued to the present. She rarely had blood in the stools. Following a recent colonoscopy, the Veteran had been advised to have the hemorrhoids surgically removed. Following examination, the examiner concluded that it was less likely than not that the hemorrhoids had their onset in or were related to service in Iraq or that they were proximately due to or aggravated by the service-connected PTSD. The rationale was that the Veteran denied hemorrhoid symptoms both prior and subsequent to service in Iraq. In addition, hemorrhoids were an anatomical abnormality around the rectum where varicose veins became inflamed or enlarged. Reasons for hemorrhoids to appear or worsen included straining, constipation, diarrhea, and pregnancy and there was no medically accepted connection between posttraumatic stress disorder and hemorrhoids. As such, the posttraumatic stress disorder did not cause or aggravate the hemorrhoids. VA treatment records include a June 2015 record wherein the Veteran denied diarrhea, constipation, bloody stools, nausea, black stools, or vomiting. The records continue to show a diagnosis of hemorrhoids, but no specific treatment. A February 2016 medical opinion is of record. The examiner noted review of the claims file and medical records. The physician indicated that he was unable to add to any of the opinions stated in March 2013 without resorting to mere speculation. The physician indicated that he had not and did not have access to the Veteran's service treatment records and that the September 2011 private physician's letter and opinion relied on a "book binder full of documents" that this physician did not have in his possession. As such, he did not have sufficient evidence to evaluate the findings articulated in the September 2011 letter. As to the April 2007 in-service treatment, the reported symptoms of fever, chills, nausea, vomiting, headache, diarrhea, and abdominal pain were not symptoms of IBS, but symptoms of an acute infectious viral gastroenteritis, which was the diagnosis at the time. There was no mention of hemorrhoids in April 2007, despite the Veteran having reported onset in January 2007 during the prior VA examination. Thus, the Veteran has advanced various theories of entitlement. One of those arguments is that her claimed disabilities are manifestations of one or more undiagnosed illnesses resulting from his service in the Southwest Asia theater of operations. In order to obtain a grant of service connection pursuant to 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, a Veteran needs to present some evidence (1) that he or she is a Persian Gulf Veteran; (2) who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either during active military, naval or air 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, 2021; and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a); see Neumann v. West, 14 Vet. App. 12, 22 (2000), vacated on other grounds, 14 Vet. App. 304 (2001) (per curiam order); Gutierrez v. Principi, 19 Vet. App. 1 (2004). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multisymptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A. § 1117(d) warrants a presumption of service-connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. 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. Medically unexplained chronic multisymptom illnesses are defined by a cluster of signs or symptoms, and are currently limited to chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases). Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2); 75 Fed. Reg. 61995-97 (Oct. 7, 2010) (adding diabetes and multiple sclerosis as examples of chronic multi-symptom illnesses of partially understood etiology and pathophysiology). 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 or injury or disease and may be related to any part of the gastrointestinal tract. Specific functional gastrointestinal disorders included, but are not limited to IBS, functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, and functional 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, pastprandial fullness, and painful or difficult swallowing. Note to 38 C.F.R. § 3.317(a)(2)(i)(B)(3). Medically unexplained chronic multisymptom illnesses are defined as a diagnosed illness without conclusive pathophysiology or etiology. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2); 75 Fed. Reg. 61995-97 (Oct. 7, 2010) (adding diabetes and multiple sclerosis as examples of chronic multi-symptom illnesses of partially understood etiology and pathophysiology). The Veteran's claimed hemorrhoids have been attributed to known clinical diagnoses and, as such, entitlement to service connection under 38 C.F.R. § 3.317 is not warranted. As to the Veteran's gastrointestinal symptoms, there is some question as to whether the Veteran has IBS or some other gastrointestinal diagnosis (such as "frequent bowel movements triggered by stress"). In any case, the Veteran's gastrointestinal symptoms have been specifically attributed to one or more specific etiologies. The July 2008 VA examiner (and the Veteran herself) have attributed her gastrointestinal problems to stress. The September 2011 private physician's letter attributed the symptoms to her service-connected posttraumatic stress disorder. In either case, the gastrointestinal problems have been attributed to a conclusive pathophysiology or etiology. As such, entitlement to service connection under the provisions of 38 C.F.R. § 3.317 is not warranted. In addition, the Veteran has argued that her hemorrhoids and gastrointestinal problems had their onset during service or are otherwise related to her active service. To establish a right to compensation for a present disability on a direct basis, a Veteran must show: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a); see also Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The sole evidence suggesting a relationship between the Veteran's hemorrhoids and gastrointestinal problems and her active service are the Veteran's current contentions of onset of symptoms while in Iraq. The difficulty with such current assertions, however, is that she has made multiple inconsistent statements as to symptom onset. As to her hemorrhoids, she has argued on occasion that they began during her service in Iraq, while on others contending that they did not begin until after her separation from service. Similarly, she has argued onset of gastrointestinal symptoms while serving in Iraq, but during her Board hearing she stated that she did not notice any problems until after returning from Iraq. In light of the foregoing inconsistencies, the Board cannot afford her contentions as to symptom onset any probative weight. The Board acknowledges the documented April 2007 complaints of gastrointestinal symptoms, but the contemporaneous record and the February 2016 VA medical opinion both attributed the symptoms to gastroenteritis, which the February 2016 VA medical opinion defined as an acute attack based on the lay and medical evidence of record. As such, the Board cannot consider this incident to constitute evidence sufficient to grant entitlement to service connection for the Veteran's current gastrointestinal problems on a direct basis. The Veteran's primary argument is that her hemorrhoids and gastrointestinal problems were caused or aggravated by her service-connected posttraumatic stress disorder. As to the hemorrhoids, the September 2011 private physician attributed the hemorrhoids to the Veteran's IBS and not directly to the mental health disorder. The Veteran has contended that her treatment provider told her that the hemorrhoids were related to her posttraumatic stress disorder, but that clearly is not the case based on the foregoing letter. To the extent that the Veteran is referring to another treatment provider, the Board recognizes that she is competent to report contemporaneous diagnoses and other information related to her by a treatment provider, but in the absence of any rationale for such a conclusion the Board finds any such conclusions by a medical provider to be of extremely limited probative value. As to the IBS, the Board acknowledges that the September 2011 private physician's letter opined as to a link between the IBS and posttraumatic stress disorder. The physician, however, provided no rationale for the conclusion, other than that the Veteran had provided information regarding such a relationship. The Board has requested that the Veteran provide this information to the Board, but she has not done so. As such, the Board finds the medical opinion to be unsupported and of extremely limited probative value. To the extent that the Veteran's contentions can be read as contending that other medical professionals have also opined such a link, the Board finds such contentions of very limited probative value for the same reasons as the hemorrhoid claim discussed above. The Board has considered the Veteran's lay contentions of a relationship between the hemorrhoids and/or IBS and her service-connected posttraumatic stress disorder. In that regard, individuals can attest to factual matters of which he or she has first-hand knowledge and the Veteran's assertions in that regard are entitled to some probative weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the etiology of the hemorrhoids and gastrointestinal problems falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). As such, the Board affords the Veteran's contentions as to the etiology of her hemorrhoids and gastrointestinal problems no probative weight. In light of the foregoing, the Board finds that the preponderance of the evidence is against the claims, and the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). The appeals must therefore be denied. ORDER Entitlement to service connection for hemorrhoids is denied. Entitlement to service connection for IBS or other gastrointestinal disability is denied. ____________________________________________ C. TRUEBA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs