Citation Nr: 20005497 Decision Date: 01/23/20 Archive Date: 01/22/20 DOCKET NO. 10-02 460 DATE: January 23, 2020 ORDER Service connection for Crohn’s disease, to include as secondary to service-connected hemorrhoids is granted. FINDING OF FACT Competent (medical) evidence reasonably establishes that the Veteran’s service-connected residuals of laparotomy with colostomy for rectal stricture with proctitis, prostate cancer, and hemorrhoids were etiological factors for the worsening of his Crohn’s disease. CONCLUSION OF LAW Secondary service connection for Crohn’s disease is warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a Veteran who served on active duty from March 1963 to September 1967 with prior active duty for training (ACDUTRA) from November 1959 to May 1960. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a July 2009 rating decision. In January 2012, a Travel Board hearing was held before the undersigned; a transcript is included in the record. In April 2012, the Board remanded the matter for additional development. In February 2016, the Board reopened the claim and remanded it for additional development and de novo consideration (considering both direct and secondary service connection). In November 2017, the Board remanded the matter for additional development. The Board notes that this matter was previously developed as a claim under §38 U.S.C. § 1151. As was noted in the Board’s remand, establishing benefits under § 1151 results in payment of compensation (as if a disability is service-connected), but is not an actual award of service connection itself. As the current decision awards service connection for Crohn’s disease (on a secondary service connection basis), the claim under § 1151 is rendered moot, and will not be further addressed. Service connection for Crohn's disease as secondary to service-connected disability is granted. Service connection may be established for disability due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. To establish service connection for a claimed disability, there must be evidence of: (i) a present claimed disability; (ii) incurrence or aggravation of a disease or injury in service; (iii) and a causal relationship between the present disability and the disease or injury in service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 U.S.C. § 3.310 (a). To substantiate a claim of secondary service connection there must be evidence of (i) a current chronic disability for which service connection is sought; (ii) an already service-connected disability; and (iii) that the already service-connected disability (a) caused or (b) aggravated the disability for which service connection is sought. See Allen v. Brown, 7 Vet. App. 439 (1995). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). The Veteran has established service connection for laparotomy with colostomy for rectal stricture with proctitis secondary to prostate cancer; prostate cancer; and hemorrhoids. A February 2012 VA gastrointestinal treatment record notes the Veteran’s chronic fecal urgency and incontinence are likely related to the reported 1985 VA hemorrhoidectomy. On January 2017 intestinal conditions examination, the diagnosis was Crohn’s disease (1990). Symptoms noted to be associated with the Crohn’s disease included diarrhea, alternating diarrhea and constipation, abdominal distension, nausea, and vomiting. Frequent episodes of bowel distress were noted. Weight loss was found to be attributable to his intestinal condition. It was noted that the Veteran developed hemorrhoids in the 1960s and underwent hemorrhoid surgery in 1985. Crohn’s disease was diagnosed in 1990, and the Veteran underwent a small bowel resection. On January 2017 intestinal surgery examination, the examiner noted the Veteran had undergone a resection of the small intestine (2007), and attributed symptoms of diarrhea, alternating diarrhea and constipation, abdominal distension, nausea, and vomiting to the intestinal surgery. The examiner opined that the Veteran’s Crohn’s disease was not related to his treatment for prostate cancer. The examiner also opined that the Veteran’s Crohn’s disease was aggravated beyond its natural progression by service-connected prostate cancer. In a September 2019 medical opinion, the consulting provider noted the Veteran was found to have hemorrhoids in service, and underwent hemorrhoidectomy sometime between 1983-1985 with subsequent injury to his external anal sphincter. The examiner noted that the cause of the Veteran’s Crohn’s disease was unknown but added that risk factors included low fiber, high animal protein/fat diet. The examiner also noted that hemorrhoidal disease was not linked to the development of Crohn’s disease, but also noted that while current literature does not suggest a link between hemorrhoids or hemorrhoid surgery as a driver for inflammatory bowel disease (IBD), the two were reported to synergize in the development of fecal incontinence, and noted that active Crohn’s disease is a relative contraindication for hemorrhoid surgery. The examiner noted that the sphincter injury (previously noted) has potential to synergize with Crohn’s disease leading to a moderate increase in Crohn’s disease symptom burden. The examiner noted that the Veteran’s March 2007 intestinal surgery was not aggravating of the Veteran’s Crohn’s disease. The examiner found that the Veteran’s hemorrhoid surgery and sphincter injury did contribute to moderately worsen his Crohn’s symptom burden in the form of worsened potential for fecal incontinence. Competent medical evidence is necessary where the determinative question requires medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The etiology of Chron’s disease, to include whether ir may have been caused or aggravated by a service-connected disability, is a medical question that requires medical knowledge. To the extent that there are conflicting medical opinions in the record regarding whether the Veteran’s Crohn’s disease was cause or aggravated by a service-connected disability, the Board notes that such conflicts may be reconciled. Notably, the January 2017 examiner limited the opinion to finding that the Veteran’s Crohn’s disease was related to the service-connected prostate cancer. Accordingly, such opinion is not directly conflicting with the September 2019 medical opinion supporting the claim. The September 2019 medical opinion addresses the ways in which hemorrhoids/hemorrhoid treatment may have caused or aggravated the Veteran’s Crohn’s disease. Notably the examiner discussed how Crohn’s disease and hemorrhoids (and given the nature of symptoms and impairment, as well as the reasoning given, now also service-connected, laparotomy with colostomy for rectal stricture and proctitis) are reported to synergize in the development of fecal incontinence, and opined that the Veteran’s initial hemorrhoid surgery and sphincter injury worsened his Crohn’s symptom burden in the form of worsened potential for fecal incontinence. Under such circumstances, the Board finds that a worsening of the Veteran’s Crohn’s disease by his service-connected disabilities is shown. Resolving reasonable doubt in his favor, as required in such circumstances (see 38 C.F.R. § 3.102), the Board finds that his Crohn’s disease is shown to have been aggravated by his service-connected disabilities to the extent that secondary service connection for Crohn’s disease is warranted. [The Board observes that rating the disability may be impacted by the provisions of 38 C.F.R. § 4.14 and the guideline for rating the disabilities listed in §§ 4.114. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Staskowski, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.