Citation Nr: 20009863 Decision Date: 02/06/20 Archive Date: 02/05/20 DOCKET NO. 16-18 538 DATE: February 6, 2020 REMANDED Entitlement to service connection for a gastrointestinal disorder, to include stomach ulcers, as secondary to the service-connected posttraumatic stress disorder (PTSD) and/or migraines is remanded. REASONS FOR REMAND The Veteran had active duty service in the United States Army from August 2001 to December 2003. This matter comes before the Board of Veteran Appeals (Board) on appeal from a July 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2019, the Veteran presented testimony before the undersigned Veterans Law Judge, and a copy of the transcript is of record. Pursuant to Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Board has recharacterized the Veteran’s claim for stomach ulcers as shown above. Entitlement to service connection for a gastrointestinal disorder, to include stomach ulcers, as secondary to the service-connected PTSD and/or migraines is remanded. The Veteran contends his stomach ulcers are directly related to his service-connected PTSD and/or migraines. The Veteran was provided a VA examination in June 2014. The examiner noted that the Veteran’s symptoms more likely correlate with dyspepsia and gastroesophageal reflux disease (GERD). The examiner further noted that an unconfirmed diagnosis of peptic ulcer noted in private treatment records is based on the Veteran’s subjective history and not a formal diagnosis usually confirmed endoscopically. The examiner opined that the cause of GERD is relaxation of the lower esophageal sphincter and unrelated to the PTSD. The examiner further opined that the cause of the Veteran’s dyspepsia is undetermined but there is no causal association between dyspepsia and PTSD based on current medical literature. In March 2019, the Veteran provided testimony at his hearing and asserted that his stomach ulcers are secondary to his PTSD and/or migraines. The Veteran reported symptoms of throbbing on one side of his temple, stomach bloating, stomach pain, weak sensation, sensitivity to light, light appetite, and frequent urination. He also reported that he experiences frequent migraines that trigger stomach pains. The Veteran also asserts that his domestic disputes triggers his PTSD, which in turn cause his stomach pains. The Board finds the June 2014 opinion is inadequate because the examiner failed to address whether the Veteran’s current gastrointestinal disorders were aggravated by the service-connected PTSD. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that if VA provides a Veteran with an examination in a service connection claim, the examination must be adequate). To that effect, establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 449 (1995); see also 38 C.F.R. § 3.310 (b). With regard to the issue of aggravation, the U.S. Court of Appeals for Veterans Claims (Court) observed that the language “not due to,” “not caused by,” or “not related to” a service-connected disability is insufficient to address the question of aggravation under § 3.310(b). Id. Furthermore, the June 2014 examiner could not determine the cause of the Veteran’s dyspepsia but relied on medical literature to support the basis for his conclusion that there is no causal connection between his dyspepsia and PTSD. Consequently, a supplemental medical opinion is required to ascertain whether the Veteran’s gastrointestinal disorders were caused by or aggravated by the service-connected PTSD and/or migraines. The matters are REMANDED for the following action: 1. With any necessary assistance from the Veteran, obtain any outstanding VA and/or private medical records. All reasonable attempts should be made to obtain identified records. 2. Obtain an addendum opinion from the examiner who conducted the June 2014 VA examination or another appropriate clinician to determine the nature and etiology of any current gastrointestinal disorders. The examiner must be provided access to the electronic claims file and indicate review of the file in the examination report. The claims folder and a copy of this remand in its entirety must be provided to the examiner in conjunction with the addendum opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and lay statements; the examiner must indicate on the examination report that such review was undertaken. If examination of the Veteran is necessary, such should be arranged. The examiner must determine: (a) all of the Veteran’s current gastrointestinal disorders, to specifically determine whether he has had stomach ulcers during the appeal period (b) whether it is at least as likely as not (50 percent probability or more) that the Veteran’s currently diagnosed gastrointestinal disorders are proximately due to his service-connected PTSD and/or migraines, or (c) whether the Veteran’s gastrointestinal disorders are chronically aggravated beyond its natural progression by his service-connected PTSD and/or migraines. The Court held that “permanent worsening” of a non-service-connected disability is not required to establish secondary service connection on the basis of aggravation. See Ward v. Wilkie (16-2157, 17-1204). The Court also recently held that causation and aggravation are independent concepts and should have separate findings and rationales. See Atencio v. O’Rourke, 30 Vet. App. 74 (2018). As such, the clinician must provide separate findings and rationales relating to causation and aggravation. (d) The examiner must also address whether it is at least as likely as not (50 percent probability or more) that any of the Veteran’s claimed gastrointestinal disorders had its onset during service or is otherwise related to Veteran’s active service. (Continued on the next page)   The examiner must provide a rationale in support of all opinions provided. If any opinion cannot be provided without resorting to speculation, the examiner must explain why this is so. 3. Readjudicate the Veteran’s claim on appeal. If the benefit sought on appeal remains denied, provide the Veteran and his representative a supplemental statement of the case and allow an appropriate period for response. L. CHU Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Y. Asfaw, 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.