Citation Nr: 21063331 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 12-33 512 DATE: October 14, 2021 ORDER Entitlement to service connection for ulcerative colitis, as secondary to service-connected posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT The preponderance of the evidence is against finding that ulcerative colitis began during active service, or is otherwise related to an in-service event, injury, or disease, to include as due to service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for ulcerative colitis, as secondary to service-connected PTSD, are not met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty with the Army from June 1974 to June 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2010 and April 2012 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). In May 2021, the Board remanded the issue on appeal for further development, and the case has since been returned to the Board. The Board finds that the agency of original jurisdiction (AOJ) has substantially complied with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Entitlement to service connection for ulcerative colitis, as secondary to service-connected PTSD The Veteran contends that his ulcerative colitis began in service as evidenced by reports of stomach issues in service and continuity of treatment. In the alternative, the Veteran contends that his service-connected PTSD has aggravated his stomach condition. In November 2018, the Veteran was afforded a VA examination for his ulcerative colitis. P.M., a nurse practitioner, opined that the Veteran's UC was less likely than not proximately due to or the result of the Veteran's service-connected condition. The examiner cited a single web article for the contention that the medical literature did not support a causal relationship between UC and PTSD. In August 2020, Z. V., M.D., the Veteran's treatment provider at a VA gastro clinic provided an opinion. Dr. V. opined that the Veteran's toxic gas exposure contributed to the Veteran's colitis. Dr. V. also opined that PTSD is closely related to colitis and the PTSD symptoms are contributed to his colitis condition. In a May 2021 Board remand, the November 2018 opinion was found to be inadequate because, in pertinent part, the examiner did not provide an opinion on whether the Veteran's service-connected PTSD aggravated his UC beyond its natural progression. Accordingly, an addendum opinion was requested. To that end, an addendum opinion was provided in July 2021. The examiner opined that the Veteran's condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The rationale provided was: There is no evidence of ulcerative colitis (UC) while in service. The separation exam is negative for any signs or symptoms remotely suggestive ulcerative colitis. Ulcerative colitis is considered an autoimmune condition and is not related to environmental exposures. The private medical opinion rendered by Dr. V is broad and general with absolutely no substantiating rationale or medical evidence to support the claim. Despite lay testimony of symptom onset and chronicity since service, the medical evidence does not support the claim. Separation exams are notably thorough and include a history, physical and veteran-answered RMH, which was specifically negative for all questions related to bowel complaints. The veteran was not diagnosed with the condition until presenting as a new patient in 2004, a span of 28 years. Though an absence of records does not constitute grounds for disqualification from service connection, it is germane in this condition. The condition is almost uniformly progressive and it is highly unlikely to have gone unnoted at separation or for a span of 28 years. The likelihood of a severe complication during that time would have been high. Psychological conditions play no established role in the development or aggravation of ulcerative colitis. There is a known association of psychological conditions and IBS, which is a diagnosis of exclusion and does not apply with the documented diagnosis of ulcerative colitis. Therefore, despite lay testimony, it is less likely than not that the veteran's UC had its nexus in service, is related to environmental exposures while in service or is due to psychological conditions, including PTSD. This is established medical knowledge and practice (Cecil's textbook of internal medicine and the treatise cited above). The claimed opiate situation is irrelevant, as opiates play no role in the development of ulcerative colitis. Any impact of environmental exposure or opiate abuse would have manifest at that time or proximate to it. Opiate abuse is more commonly associated with constipation and is not associated with bloody diarrhea. The article is not sufficient to establish the veteran's claim nor does it establish a relationship between UC. The veteran categorically does not have IBS. You cannot be diagnosed with IBS when there is a documented etiology for the veteran's bowel symptoms. They are mutually exclusive. The above applies to aggravation as well. The treatise suggests possible aggravation due to stress and anxiety but this is misleading, as it does not alter the baseline condition, only accounting for occasional increased frequency of BMs, which has not been documented in the veteran's case. Furthermore, there is no evidence of aggravation beyond the natural course due to any cause. The condition is almost uniformly progressive in the absence of treatment. Some individuals are resistant to treatment. As stated above, in an effort to assist his patient, Dr. V did not present a plausible rationale and the article submitted is irrelevant, as it addresses IBS and not UC. Had the diagnosis been UC, Dr. V's opinion might have been germane. The examiner also opined that the Veteran's condition was less likely than not proximately due to or aggravated by the Veteran's service-connected condition with the same rationale provided above. The remaining evidence indicates continued complaints and treatment of ulcerative colitis but no discussion on its etiology. Based on the foregoing evidence of record, the Board finds that service connection is not warranted. The Board finds the July 2021 VA addendum opinion of record the most probative evidence of record as to the etiology of the Veteran's ulcerative colitis condition because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Further, while it is noted that the record contains a medical opinion stating otherwise, the Board finds that this opinion is afforded less probative value. Indeed, this August 2020 opinion failed to provide any rationale in support of the opinion itself. The Board considered the Veteran's lay assertions as to the etiology of his claimed disability. Although the Veteran is competent to attest to his experiences, he is not competent in these circumstances to opine as to the etiology of his ulcerative colitis condition. The Veteran has not been shown to have specialized medical knowledge that would be necessary to provide a competent opinion regarding service connection. The Board finds the July 2021 VA opinion of record to be more probative in this regard. The examiner considered the Veteran's history, and ultimately concluded that from a medical perspective, it is less likely that his claimed disability is related to service nor was it proximately due to or aggravated by his service-connected PTSD. In conclusion, the weight of the evidence is against the claim for service connection for ulcerative colitis condition. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. A. Elliott II, 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.