Citation Nr: 21061362 Decision Date: 10/01/21 Archive Date: 10/01/21 DOCKET NO. 11-32 554 DATE: October 1, 2021 REMANDED Entitlement to service connection for irritable bowel syndrome (IBS) is remanded. Entitlement to service connection for an upper gastrointestinal disorder, to include hiatal hernia and gastroesophageal reflux disease (GERD), is remanded. Entitlement to service connection for fibromyalgia is remanded. Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1988 to December 1990. This case comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision from the Department of Veterans Affairs (VA) Regional Office in St. Louis, Missouri. In April 2018, the Board granted service connection for PTSD due to military sexual trauma, and remanded the remaining issues for additional development. The appeal was last remanded in November 2019.\ Entitlement to service connection for irritable bowel syndrome (IBS) is remanded. Entitlement to service connection for an upper gastrointestinal disorder, to include hiatal hernia and gastroesophageal reflux disease (GERD), is remanded. Entitlement to service connection for fibromyalgia is remanded. Entitlement to service connection for a low back disability is remanded. While the Board sincerely regrets the additional delay, more development is required before the Board may make determinations on the merits of the Veteran's claims. In the November 2019 remand, the Board noted that the Veteran contends, in part, that her IBS is related to an in-service sexual assault. She asserts that a rectal assault resulted in IBS. See January 2013 Hearing Transcript. The Veteran further argues that there is a relationship between her IBS and in-service treatment for gastroenteritis, and she submitted medical articles on the relationship between gastroenteritis and IBS in August 2015. On remand, the Board instructed the RO to obtain an addendum medical opinion regarding the Veteran's sexual assault, and/or gastroenteritis and IBS. In so doing, it was noted that the addendum must reflect consideration of the articles submitted by the Veteran in support of her claim and her January 2013 testimony. An addendum opinion was provided in July 2021. In that opinion, the examiner stated "[t]here is no evidence of a military sexual assault in the provided STRs...there is no evidence documenting that sexual assault (with rectal trauma) or history of multiple episodes of gastroenteritis, directly or indirectly caused irritable bowel syndrome. Furthermore, there is no plausible pathophysiologic mechanism discussed in the medical literature and known medical principles that would explain such a causal relationship between these conditions." In so finding that there was no pathophysiologic mechanism in medical literature showing a causal relationship between IBS and gastroenteritis, the examiner neglects entirely to address the article entitled "Relationship between infections gastroenteritis and irritable bowel syndrome" submitted by the Veteran in August 2015. Further, in April 2018, the Board granted service connection for posttraumatic stress disorder as due to sexual trauma. In stating that there was no evidence of a military sexual assault in the Veteran's service treatment records, the examiner impermissibly re-adjudicated service connection for PTSD. As the examiner failed to address the medical evidence as requested, the Board finds the examination inadequate and a new examination is required. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (Once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one). Stegall v. West, 11 Vet. App. 268, 271 (1998). In so doing, the examiner is reminded that he or she is asked to make medical determinations (whether the medical evidence demonstrated rectal trauma or related symptoms and whether such is related to IBS) as opposed to factual ones. Regarding the Veteran's claim for an upper gastrointestinal disorder, in a March 2021 addendum opinion, the examiner provided a positive nexus between IBS and GERD, as such, adjudication of the GERD claim is inextricably intertwined with the IBS development. Harris v. Derwinski, 1 Vet. App. 180 (1991). Remand of the inextricably intertwined claim is therefore required. Turning to the Veteran's fibromyalgia and low back claims, regrettably, the opinions provided following the November 2019 Board remand are also inadequate. In March 2021, the examiner found that a low back disorder was less likely than not related to her IBS. In so finding, the examiner stated as his rationale that a review of the Veteran's records did not provide any documentation that the Veteran's IBS was attributed to her IBS. This, however, is not a medical opinion. The examiner was asked on remand to review the evidence of record and provide a medical opinion as to whether there was a medical relationship between IBS and a lower back disorder. A new opinion is necessary to provide an adequate medical opinion. Finally, an addendum opinion regarding the Veteran's fibromyalgia states that there was no evidence documenting that irritable bowel syndrome directly or indirectly caused fibromyalgia. However, as noted by the Veteran in August 2015, the evidence includes a November 17, 2005 treatment record from Waterloo Internal Medicine wherein it is noted that the Veteran had a diagnosis of diffuse myalgia secondary to fibromyalgia, symptoms consistent with irritable bowel syndrome. Thus, on remand, an examiner is asked to address these findings and to render a medical opinion as to whether fibromyalgia may be related to IBS. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician on whether the Veteran's IBS is related to, proximately due to, or aggravated by in-service sexual (rectal) assault and/or gastroenteritis. The addendum must reflect consideration of the Veteran's January 2013 testimony, and the medical articles on the relationship between IBS and gastroenteritis submitted by the Veteran. See August 2015 Argument and Evidence in Support of Appeals. 2. Obtain an addendum opinion from an appropriate clinician on whether the Veteran's fibromyalgia is related to, proximately due to, or aggravated beyond its natural clinical course by IBS. The addendum must reflect consideration of the Waterloo Internal Medicine treatment note dated November 17, 2005. 3. Obtain an addendum opinion from an appropriate clinician on whether the Veteran's chronic low back pain is related to, proximately due to, or aggravated beyond its natural clinical course by IBS. 5. Review the addendum opinions to ensure substantial compliance with the Board's directives. Take any necessary corrective action. 6. Readjudicate the claims on appeal. If any of the claims remain denied, issue a supplemental statement of the case and allow the Veteran and her attorney the opportunity to respond. Then return to the Board for further appellate review. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Slovick, 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.