Citation Nr: 18155349 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 18-07 138 DATE: December 4, 2018 REMANDED Entitlement to service connection for a gastrointestinal condition is remanded. Entitlement to service connection for a lower back condition with muscle and joint pain is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected posttraumatic stress disorder (PTSD) and/or sleep apnea, is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from January 1978 to April 1993. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina (Agency of Original Jurisdiction (AOJ)). 1. Entitlement to service connection for a gastrointestinal condition The Veteran filed a claim for service connection for a gastrointestinal condition in January 2014. The record reflects that the Veteran underwent surgery as an infant due to Hirshsprung’s Disease, which has been medically described as a congenital disease present at birth due to missing nerves which control muscle movement. The Veteran’s service treatment records (STRs) reflect multiple treatments for abdominal pain including an instance of small bowel obstruction with a post service history significant for additional small bowel obstructions. A December 1977 enlistment examination reflected a history of abdominal surgery at 3 months of age. A 2015 VA examiner attributed the Veteran’s bowel obstruction in service to a natural progression of Hirshsprung Disease, but a March 2015 Disability Benefit Questionairre prepared by the Veteran’s treating physician noted that a Whipple procedure for pancreatic cystic lesion revealed adhesions and internal hernias. The Board finds that additional opinion is needed to clarify whether any of the Veteran’s current gastrointestinal disorders had their onset in service. 2. Entitlement to service connection for a lower back condition with muscle and joint pain is remanded. The Board notes that the Veteran had a VA examination for his lower back in July 2016. At that time, the examiner recorded that the Veteran did not have a current diagnosis associated with his lower back condition with muscle and joint pain. However, recent VA treatment records note a diagnosis of displacement of lumbar intervertebral disc. Similarly, imaging from August 2014 noted lumbar spondylitic changes, and in March 2013, degenerative endplate changes were recorded (though the physician indicated a negative lumbar spine radiograph). To afford the Veteran due process, the Board will remand for a new VA examination and instruct the examiner to consider this evidence when determining his or her diagnosis and the etiology of the Veteran’s lower back condition. 3. Entitlement to service connection for erectile dysfunction is remanded. The record reflects that the Veteran has not yet received a VA examination for erectile dysfunction. Furthermore, there are no medical opinions of record that suggest an etiology for this condition. The Board will therefore remand to afford the Veteran an opportunity to present for this examination and to obtain an opinion as to the etiology of his erectile dysfunction. The matters are REMANDED for the following action: 1. The AOJ shall associate the Veteran’s most recent outstanding VA medical treatment records with his file, specifically those records from August 2018 to the present. Additionally, attempt to obtain the surgical report for the Veteran’s Whipple Procedure. 2. Then, schedule the Veteran for an examination by an appropriate medical doctor to determine the nature and etiology of any gastrointestinal condition. The examiner must opine whether it is at least as likely as not (50 percent probability or more) that the Veteran’s Hirshsprung’s Disease increased in severity during service or any increase in disability was due to the natural progress of the preexisting condition? The examiner is requested to specifically discuss the underlying medical cause for the Veteran’s 1991 hospital treatment for small bowel obstruction and compare the 2015 VA examiner opinion that such bowel obstruction in service was a natural progression of Hirshsprung’s Disease while a 2015 DBQ noted that a Whipple Procedure found adhesions and internal hernias. For any other gastrointestinal disorder other than Hirshsprung’s Disease, to include gastroesophageal disease (GERD), colonic diverticulosis, small bowel resection for gastrointestinal bleeding with possible history of small arteriovenous malformations (AVMs) and cystic lesion on pancreas, whether it is at least as likely as not (probability of 50% or greater) that such disorder had its onset in or is otherwise related to service? The examiner is specifically requested to discuss whether there is any medical reason to accept or reject the Veteran’s belief that his report of gastrointestinal symptoms in service and thereafter represented the onset of these disorders in service. In providing this opinion, the examiner’s attention is directed towards the following: • a December 1977 entrance examination noting questionable pyloric stenosis and history of abdominal surgery at 3 months old; • the Veteran’s in-service history of treatment for gastrointestinal symptoms variously diagnosed as diarrhea of probable bacterial origin, diarrhea secondary to altered fecal flora, viral gastroenteritis, and small bowel obstruction; and • an August 11, 2014 VA gastroenterology consultation report which accurately summarized the Veteran’s treatment history as well as the type of surgery performed as an infant, The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. The Veteran should be afforded an appropriate VA examination in order to determine the current nature and etiology of his lower back condition. The claims file must be made available to and be reviewed by the examiner. The examiner should specifically indicate whether the Veteran has a lower back condition with joint and muscle pain, and provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such lower back condition with joint and muscle pain occurred in or is otherwise etiologically related to the Veteran’s military service, including the rigors of the Veteran’s military duties. The examiner should accept as fact that the Veteran has a present diagnosis for his lower back condition given that recent VA treatment records note a diagnosis of displacement of lumbar intervertebral disc, imaging from August 2014 was interpreted as showing lumbar spondylitic changes, and in March 2013, degenerative endplate changes were recorded (though the physician indicated a negative lumbar spine radiograph). The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 4. The Veteran should be afforded an appropriate VA examination in order to determine the current nature and etiology of his erectile dysfunction. The claims file must be made available to and be reviewed by the examiner. The examiner should specifically indicate whether the Veteran has erectile dysfunction, and provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such erectile dysfunction occurred in or is otherwise etiologically related to the Veteran’s military service, to include his service-connected PTSD and/or sleep apnea and/or medications used to treat PTSD. The examiner should consider the following: • a February 1995 VA Persian Gulf Examination report and an April 1995 psychiatric consultation wherein the Veteran described the onset of erectile dysfunction in December 1993; and • the Veteran’s April 2016 Statement in Support of Claim for PTSD, documenting sexual difficulties. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. (continued on next page) 5. Thereafter, readjudicate the claim. If any benefit sought on appeal remains denied, furnish the Veteran and his representative, if any, a supplemental statement of the case and an appropriate period of time to respond. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Victoria A. Narducci, Associate Counsel