Citation Nr: 18155665 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 18-19 013 DATE: December 4, 2018 REMANDED Entitlement to service connection for hematemesis, to include as secondary to medications taken for service-connected disability, is remanded. Entitlement to service connection for gastropathy, to include as secondary to medications taken for service-connected disability, is remanded. Entitlement to service connection for internal hemorrhoids, to include as secondary to service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 2001 to June 2001, July 2003 to June 2005, and February 2009 to April 2010, to include service in Southwest Asia from April 2009 to January 2010. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in October 2017 by a Department of Veterans Affairs (VA) Regional Office. 1. Entitlement to service connection for hematemesis, to include as secondary to medications taken for service-connected disability. 2. Entitlement to service connection for gastropathy, to include as secondary to medications taken for service-connected disability. 3. Entitlement to service connection for internal hemorrhoids, to include as secondary to service-connected disability. In documents of record, the Veteran contends that he has hematemesis, gastropathy, and internal hemorrhoids related to his in-service exposure to environmental hazards consistent with his service in Southwest Asia. As an initial matter, the Board notes that such disorders have been clinically diagnosed and, consequently, consideration of such as undiagnosed illnesses or medically unexplained chronic multisymptom illnesses is not warranted. Further, at an October 2017 VA examination, the examiner found that the Veteran’s hematemesis, gastropathy, and internal hemorrhoids were less likely than not related to his exposure to environmental hazards in Southwest Asia as such disorders do not result from such type of exposures. In this regard, he noted that such disorders have other likely causes. For hematemesis, such includes aspirin and, for gastropathy, such includes bile-reflux NSAIDs. In regard to the latter disorder, the examiner noted that the Veteran had a history of using Tramadol, and reported that Naproxen made his stomach upset. Further, he observed that likely causes of hemorrhoids include straining during a bowel movement, complications from chronic constipation, and sitting on the toilet for a long time. Upon review of the record, the Veteran is service-connected for unspecified anxiety disorder with insomnia, lumbosacral strain, tinnitus, and radiculopathy of the right lower extremity, and his treatment records reflect that he has taken a variety of medications for his psychiatric disability as well as Tramadol and Naproxen for his back disability. Consequently, as the October 2017 VA examiner’s opinion raised the possibility that the medications taken for the Veteran’s service-connected disabilities may have caused or aggravated his hematemesis and gastropathy, the Board finds that a remand is necessary in order to obtain an addendum opinion addressing such matter. Furthermore, as the October 2017 VA examiner’s opinion suggests that the Veteran’s gastropathy may have caused or aggravated his internal hemorrhoids, an addendum opinion addressing such matter should also be obtained. The matter is REMANDED for the following action: Return the record to the VA examiner who conducted the October 2017 examination. The record and a copy of this Remand must be made available to the examiner. If the October 2017 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of the record, the examiner should address the following inquiries: (A) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the medications taken for the Veteran’s service-connected disabilities of unspecified anxiety disorder with insomnia, lumbosacral strain, tinnitus, and radiculopathy of the right lower extremity, which include Tramadol and Naproxen, caused or aggravated his diagnosed hematemesis? For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. (B) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the medications taken for the Veteran’s service-connected disabilities of unspecified anxiety disorder with insomnia, lumbosacral strain, tinnitus, and radiculopathy of the right lower extremity, which include Tramadol and Naproxen, caused or aggravated his diagnosed gastropathy? For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. 1. (C) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s gastropathy caused or aggravated his diagnosed internal hemorrhoids? For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology In offering such opinions, the examiner should review the October 2017 VA examination that includes a discussion of possible etiologies of hematemesis, gastropathy, and internal hemorrhoids. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Robert Almosd, Associate Counsel