Citation Nr: 21001304 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 07-09 271 DATE: January 7, 2021 ORDER Service connection for a bowel disorder to include irritable bowel syndrome (IBS), including as secondary to service-connected lumbar spine degenerative disc disease and/or as secondary to medication required to treat service-connected posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT A bowel disorder to include IBS is not shown to be causally or etiologically related to any disease, injury, or incident during service, and is not caused or aggravated by a service-connected disability, to include the medication prescribed to treat such. CONCLUSION OF LAW The criteria for entitlement to service connection for a bowel disorder to include IBS, including as secondary to service-connected lumbar spine degenerative disc disease and/or as secondary to medication required to treat service-connected PTSD, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from October 1990 to February 1993, including in the Southwest Asia Theater of Operations during the Persian Gulf War. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office in Waco, Texas. The Veteran testified at a hearing held before the undersigned Veterans Law Judge in September 2016. A transcript of that hearing has been associated with the record. This claim was previously before the Board in May 2012, January 2016, May 2017, April 2018, and July 2020, at which times it was remanded for additional development. The Board finds that there has now been substantial compliance with its latest remand instructions, and it can proceed to final appellate review. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order). Finally, the Board notes that in an August 2020 letter, the Veteran’s appointed attorney attempted to withdraw his representation of the Veteran. After an appeal is certified to the Board, a representative may not withdraw unless good cause is shown on motion. Good cause includes the extended illness or incapacitation of the representative; failure of the appellant to cooperate with proper preparation and presentation of the appeal; or other factors which make the continuation of representation impossible, impractical, or unethical. 38 C.F.R. § 20.608 (b)(2). Here, the attorney has not provided good cause or state any cause for doing so. Therefore, the Board does not recognize the withdrawal and finds that the attorney still represents the Veteran in this appeal. The Veteran seeks service connection for a bowel disorder to include IBS, including as secondary to service-connected lumbar spine degenerative disc disease and/or as secondary to medication required to treat service-connected PTSD. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). 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) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310 (b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran contends that he developed a bowel disorder, to include IBS, due to his military service. In the alternative, he asserts that he developed such a disorder as due to his service-connected lumbar spine degenerative disc disease and/or as secondary to medication required to treat service-connected PTSD. The Veteran’s service treatment records show that in May 1992 he was seen with complaints of gas, which occurred whenever he ate. In a September 1993 Report of Medical History, the Veteran reported that he experienced stomach, intestinal trouble and frequent indigestion. In October 2012, the Veteran underwent a VA examination. The examiner was asked at that time to opine as to the etiology of any diagnosed bowel disorder. The examiner confirmed a diagnosis of IBS, with a 2002 onset date. He acknowledged the Veteran’s ten-year history of alternating constipation and diarrhea, along with excessive gas, and noted that until the examination the Veteran had not been formally diagnosed with IBS. He noted the Veteran’s complaints of epigastric, per-umbilical, and bilateral lower quadrant pain with hyperactive bowel movements. Upper gastrointestinal series testing in 1998 was negative and a 2008 ultrasound was normal. The examiner concluded that the Veteran’s IBS was not due to his service-connected lumbar spine disability, nor was there any association with the medication he took to treat his service-connected PTSD. In support of these conclusions, the examiner explained that IBS is a defined clinical entity that is not associated with the lumbar spine. The Veteran had multiple lumbar x-rays and MRIs and the findings have always shown minimal degenerative joint disease without intervertebral disc syndrome and no neuroforaminal encroachment. As for the PTSD medication, the examiner explained that while the Veteran’s medication can rarely cause vomiting, anorexia, constipation or diarrhea, he only recently started taking the medication but had long-standing gastrointestinal complaints stretching back many years. At his September 2016 hearing before the Board, the Veteran testified that he began to have stomach issues after eating MREs in service, and that he continued to experience gastrointestinal issues such as severe constipation or diarrhea since. In June 2017, the Veteran was again examined by VA. The examiner concluded that it was less likely than not that the Veteran’s IBS was incurred in, or caused by, his military service. However, to support this conclusion, the examiner explained that the Veteran did not have a diagnosis of IBS. As noted by the Board in its April 2018 remand, this examination is based on inaccurate information and is inadequate for purposes of deciding the claim. In August 2019, the Veteran underwent a VA examination. In an October 2019 addendum opinion, a VA examiner concluded it was less likely than not that the Veteran’s IBS was caused by, due to, or developed in, service. As rationale, the examiner acknowledged the in-service documentation of some gastrointestinal problems such as frequent indigestion. However, while these symptoms were suggestive of IBS, an actual in-service diagnosis could not be determined. IBS is a gastrointestinal disorder characterized by altered bowel habits associated with abdominal pain in the absence of detectable structural and biochemical abnormalities. However, the Veteran only experienced frequent indigestion, or conditions related thereto. Additionally, there was a 19-year gap between his separation from service and his formal diagnosis of IBS. Thus, it was less likely that IBS was caused by, due to, or began in, service. In October 2020, a final VA examination was provided to address the question of aggravation of the Veteran’s diagnosed IBS by his PTSD medication. The examiner concluded that it was less likely than not that the Veteran’s IBS was aggravated beyond its natural progression by the medication. She explained that IBS is a gastrointestinal disorder characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause. The pathophysiology of IBS is uncertain, but it is viewed as a disorder resulting from an interaction of multiple factors. Because of this, it would not be possible to determine which factors, such as medication, could aggravate the condition, without resorting to speculation. Based on this evidence, the Board finds that the claim must be denied. It places great probative weight on the October 2012, 2019 and 2020 VA examination reports, as they each were authored based on a consideration all of the pertinent evidence of record, to include the statements of the Veteran, and the examiners provided complete rationale, each relying on and citing to the records reviewed. Moreover, the examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). As for the October 2020 opinion, the Board notes that VA can accept an examiner’s statement that an opinion cannot be provided without resorting to speculation. Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). In Jones, the United States Court of Appeals for Veterans Claims (Court) held that simply concluding that the etiology of a disability could not be resolved without speculation without providing any further explanation was inadequate. However, the Court stated that an examination report “should clearly identify precisely what facts cannot be determined. For example, it should be clear in the examiner’s remarks whether it cannot be determined from current medical knowledge... or that the actual cause cannot be selected from multiple potential causes.” Id. at 390. Here, although the October 2020 VA examiner indicated that it would be impossible to determine aggravation, she explained that there were multiple factors which caused or constituted IBS, this making the determination of aggravation of any individual factor impossible. As such, the Board finds that the October 2020 VA examiner’s conclusion that it would be speculation to opine whether the Veteran’s IBS is aggravated by his PTSD medication is sufficiently supported by a thorough rationale. The Board has considered the Veteran’s statements that his bowel disorder is directly related to his service and/or secondary to a service-connected disability, to include medication to treat PTSD; however, as a lay person, he has not shown that he has specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of such disorder is a matter not capable of lay observation and requires medical expertise to determine. Specifically, the question of etiology of a bowel disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship as it requires the administration and interpretation of specialized testing, and determining the etiology of such requires knowledge of the gastrointestinal system. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Moreover, whether the symptoms the Veteran reportedly experienced during or after service are in any way related to his currently diagnosed bowel disorder, to include IBS, is a matter that also requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) (“although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with.”). Accordingly, the Veteran’s opinion as to the onset and etiology of his disability is not competent evidence and, consequently, is afforded no probative weight. In sum, the Board finds the Veteran’s bowel disorder, to include IBS, is not shown to be causally or etiologically related to any disease, injury, or incident during service, and is not shown to be caused by a service-connected lumbar spine disability or aggravated by a service-connected psychiatric disability, to include the medication taken to treat such. In reaching its decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection. As such, that doctrine is not applicable in the instant appeal. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. The claim is denied. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jeremy J. Olsen, 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.