Citation Nr: 18146367 Decision Date: 10/31/18 Archive Date: 10/31/18 DOCKET NO. 16-33 476 DATE: October 31, 2018 REMANDED Entitlement to service connection for irritable colon syndrome is remanded. Entitlement to service connection for hemorrhoids, to include as secondary to irritable colon syndrome is remanded. REASONS FOR REMAND The Veteran had active service in the United States Navy from July 1998 to July 2001 and from June 5, 2009 to January 2011, with additional periods in the U.S. Reserves. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) 1. Entitlement to service connection for irritable colon syndrome is remanded. The Veteran contends that he is entitled to service connection for irritable colon syndrome (also known as irritable bowel syndrome, or IBS) because he began experiencing symptoms shortly after he was discharged from service in January 2011 and was diagnosed with IBS in October 2013. The Veteran also stated that he was exposed to burning trash during his service in Afghanistan. To obtain service connection under 38 U.S.C. §§ 1110, 1131 and 38 C.F.R. § 3.303 (a) a Veteran must satisfy a three-element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so- called ‘nexus’ requirement. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013). The VA and private medical records show that the Veteran has reported symptoms of IBS since June 2011, in the form of abdominal pain, diarrhea, nausea, constipation, bloating and abdominal cramps. Also, during an April 2013 VA examination, the examiner opined that the Veteran’s diarrhea is related to an in-service exposure and diarrhea is a symptom of IBS. In providing this medical opinion, the examiner was asked to respond to the following question: whether the Veteran’s IBS was incurred or caused by diarrhea that occurred in service? It is unclear whether the examiner, in responding to the question, mistakenly believed that the Veteran was a Gulf War Veteran. It is also unclear to what “in-service exposure” the examiner was referring in his rationale. Due to the inadequacy of this VA examination, and given that the Veteran does not meet the definition of a Gulf War Veteran for VA purposes under 38 C.F.R. § 3.317(e), it is necessary to obtain a new medical opinion to establish the nexus element of the claim for service connection. Cox v. McDonald, 28 Vet. App. 318 (2016) (holding that service in Afghanistan is not considered service in Southwest Asia, except for consideration of infectious diseases under 38. C.F.R. § 3.317(c)). It is also unclear from the medical evidence, whether the Veteran has in fact been diagnosed with irritable colon syndrome, IBS, or any other gastrointestinal disability. During the April 2013 VA examination, the examiner indicated that that the symptoms reported by the Veteran during a previous August 2011VA examination were compatible with a diagnosis of IBS. Private treatment records, dated June 2012, from Trinity Gastroenterology reflect a diagnosis for diarrhea (IBS suspected). The Veteran was re-examined by the same private physician in October 2013. During this examination, the Veteran was diagnosed with diarrhea (IBS). Although the April 2013 VA medical opinion assumed that the Veteran had a diagnosis of IBS, the diagnostic code provided by the private examiner in October 2013 was for diarrhea. It is unclear what the physician intended by noting IBS in parentheses as part of the diagnosis. Therefore, a new examination is required not only to determine the nexus element of the claim for service connection, but also to clarify the Veteran’s gastrointestinal diagnosis, if any. 2. Entitlement to service connection for hemorrhoids, to include as secondary to service-connected irritable colon syndrome is remanded. In his Notice of Disagreement to the Board, dated December 2013, the Veteran claimed that his hemorrhoids were secondary to his IBS. There is no evidence in the Veteran’s service treatment records that he complained of, was treated for, or had symptoms of hemorrhoids during his military service. Therefore, the only means by which the Veteran could be service connected for hemorrhoids is through secondary service connection. The Veteran underwent a colonoscopy in January 2012 at a VA facility because he was experiencing rectal bleeding. Following the procedure, the VA examiner diagnosed with Veteran was hemorrhoids. In a March 2012 Gastroenterology Note, the examiner reported that the Veteran denied having any more episodes of rectal bleeding and reported that the problem occurs “every now and then” with hard stools. During a November 2017 Nursing Intake Note that Veteran continued to report that, at times, he had constipation with rectal bleeding. The Board notes that the Veteran’s claim for secondary service connection for hemorrhoids is inextricably intertwined with his service connection claim for irritable colon syndrome because one of the key elements of a secondary service connection claim is evidence of a service connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448-49 (1995); El-Amin v. Shinseki, 26 Vet. App. 136 (2013). Therefore, the determination of whether the Veteran will be entitled to service connection for hemorrhoids on a secondary basis will, in part, be based on whether there will be medical evidence showing a diagnosis for irritable colon syndrome, IBS or another gastrointestinal disability. Also, there is no current medical examination confirming whether the Veteran continues to have hemorrhoids. Moreover, there is no medical examination that links the Veteran’s hemorrhoids to his claimed irritable colon syndrome or IBS. Therefore, the Board defers adjudication of the Veteran’s secondary service connection claim for hemorrhoids until the development requested for the service connection claim for irritable colon syndrome is accomplished, medical evidence is obtained to confirm whether the Veteran continues to have a diagnosis for hemorrhoids, and a causal relationship is shown between the Veteran’s hemorrhoids and his irritable colon syndrome. The matters are REMANDED for the following action: 1. Obtain any outstanding VA and private treatment records to be associated with the Veteran’s claims file. 2. Schedule the Veteran for an examination by an appropriate clinician to determine whether there is a diagnosis of a gastrointestinal disability, to include the claimed irritable colon syndrome, IBS or another gastrointestinal disability. The electronic claims file, to include the Veteran’s service treatment records, lay statements and testimonies, and treatment records, must be reviewed by the examiner, and a note that it was reviewed should be included in the report. After reviewing the claims file and examining the Veteran, the examiner should opine to the following: whether the Veteran’s gastrointestinal disability (including irritable colon syndrome, IBS or another gastrointestinal disability) is at least as likely as not related to an in-service injury, event, or disease, including the Veteran’s claimed exposure to burning trash. The examiner should also explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. The examiner should also explain the reasons behind any opinions expressed and conclusions reached. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). 3. Assuming the VA examiner concludes that the Veteran has a diagnosis of irritable colon syndrome, IBS or another gastrointestinal disability, schedule the Veteran for an examination by an appropriate clinician to determine whether the Veteran continues to have a diagnosis for his claimed hemorrhoids disability. If the examiner continues the diagnosis for hemorrhoids, and after reviewing the claims file and examining the Veteran, the examiner should opine to the following: whether the Veteran’s hemorrhoids are at least as likely as not (1) proximately due to his IBS, irritable colon syndrome, or other gastrointestinal disability, or (2) aggravated beyond its natural progression by his service-connected IBS, irritable colon syndrome or other gastrointestinal disability. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones, 23 Vet. App. at 390. 4. Thereafter, complete any other development deemed necessary and then readjudicate the Veteran’s service connection claim. If a complete grant of the benefits requested is not awarded, issue a supplemental statement of the case to the Veteran and his representative, and provide them an opportunity to respond before returning the case to the Board. Michael Pappas Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. White, Associate Counsel