Citation Nr: 21066301 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 16-49 868A DATE: October 29, 2021 REMANDED Entitlement to service connection for a digestive condition is remanded. REASONS FOR REMAND The Veteran served in the United States Air Force from December 1976 to October 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an October 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge at a September 2019 videoconference hearing, and a transcript of this hearing is associated with the claims file. This matter was previously before the Board in December 2019 and June 2021, and both times the Board remanded the matter in order to obtain an adequate VA medical examination. Entitlement to service connection for a digestive condition is remanded. Service connection will be granted if the evidence in the record demonstrates that a current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) an in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). The Veteran's service treatment records show multiple reports of gastrointestinal symptoms. He reported having constipation in November 1978; a May 1979 treatment note shows the Veteran complained of stomachache, nausea, diarrhea, and fever; an October 1979 separation examination notes complaints of frequent indigestion; and a December 1979 diagnosis of viral gastroenteritis. His VA treatment records do not show consistent complaints of indigestion, IBS, or related symptoms. During the September 2019 hearing, the Veteran testified that he began experiencing what he referred to as a "nervous stomach" while stationed in South Korea. He explained that the medical technician told him to take antacids for his stomach issues, and the Veteran began taking antacids and still takes Rolaids for his stomach. He described how his stressful work environment in South Korea made his stomach condition worse. Additionally, he reported that although he did not seek medical treatment through the VA, he had seen doctors in Mexico for his indigestion issues. The Veteran underwent a VA examination in January 2020, in which the examiner diagnosed him with irritable bowel syndrome (IBS). He reported having alternating diarrhea and constipation, with loose watery stools one to two days a week and constipation three to four days a week, along with a full, distended feeling of being bloated and nausea, especially after eating a heavy meal. The examiner opined the Veteran's digestive disorder was less likely than not caused by service because the symptoms he had during service were considered acute only. The examiner also found no chronicity of care. However, in its June 2021 remand, the Board found the January 2020 VA examination to be inadequate because it failed to address the Veteran's noted in-service reports of gastrointestinal symptoms in May 1979, October 1979, and his separation examination, as well as a December 1979 diagnosis of viral gastroenteritis. As such, the Board instructed the RO to obtain an addendum medical opinion, which the RO complied with in July 2021. In the July 2021 VA records review examination for IBS, the examiner noted the Veteran had a diagnosis of IBS and reported he began experiencing issues with abdominal pain, bloating, and alternating diarrhea and constipation when he was in service, and these symptoms continued after service. The examiner opined that the Veteran's digestive issues were less likely than not due to service because the gastrointestinal symptoms noted during service would not be consistent as an indicating factor for IBS. The examiner further opined that although the Veteran's separation examination noted issues with frequent indigestion, there are no other specified symptoms that would support a diagnosis of IBS, including complaints of diarrhea or constipation. In addition to addressing the gastrointestinal symptoms noted in service, the examiner addressed the statements made by the Veteran during his September 2019 hearing testimony. The examiner noted that while the Veteran endorsed frequent indigestion since separation from service, he did not mention any issues with bowel movements. In order to meet the current diagnostic criteria for IBS, there must be an association with abdominal pain and defecation and a change in bowel form or regularity; however, the Veteran did not mention these symptoms and thus a diagnosis of IBS is not supported. Additionally, a VA records review examination for esophageal disorders was conducted in July 2021. The examiner noted the Veteran had no diagnosed esophageal disorders, although he reported experiencing abdominal pain, bloating, and alternating diarrhea and constipation from service to present. However, the examiner found that the Veteran presented no symptoms of an esophageal disorder, and thus opined there was no objective evidence to support a current diagnosis of an esophageal disorder. The Board finds the July 2021 examiner's opinion to be of high probative value with respect to whether the Veteran's IBS is due to or otherwise related to service. While the Veteran experienced gastrointestinal symptoms during service, he was diagnosed with infectious gastroenteritis, which the examiner explained would not be consistent as an inciting factor for IBS. Additionally, although the Veteran reported experiencing indigestion on his separation examination, he did not report any specific symptoms that would support a diagnosis of IBS, including diarrhea or constipation. The examiner further opined that during his September 2019 testimony, the Veteran did not describe experiencing any frequent bowel movements either during service or continuously since service. The Veteran's VA treatment records also lack consistent complaints of IBS or related symptoms, with these complaints first appearing in the January 2020 examination. The July 2021 examiner explained that diagnostic criteria for IBS requires an association with abdominal pain and bowel movements, as well as changes in bowel form and regularity, and because the Veteran did not have continuous symptoms, the examiner found that he did not have a diagnosis of IBS continuously since service. However, the Board finds the July 2021 examiner's opinion to be inadequate with respect to whether his symptoms of indigestion are due to or otherwise related to service. During his hearing testimony, the Veteran stated that his stressful work during service caused his nervous stomach and indigestion, and he continues to experience these symptoms daily. Additionally, he stated that while he is not being treated for these symptoms at VA, he takes over the counter antacids, primarily Rolaids, to deal with his symptoms. Further, although the Veteran does not have many complaints of indigestion in his VA treatment records, he has provided consistent statements concerning the nature of his indigestion symptoms. But, while the examiner touched on the Veteran's indigestion and use of antacids in the IBS examination opinion, there is no mention of these symptoms or the use of antacids in the esophageal disorder examination opinion. In its June 2021 remand, the Board instructed the examiner to address the Veteran's statements concerning in-service symptoms and his reported symptoms and medications since separation from service. A remand by the Board confers on the claimant a legal right to compliance with the remand orders. See Stegall v. West, 11 Vet. App. 268, 271 (1998). A failure by the Board to ensure that its remand orders are complied with constitutes legal error. Id. Therefore, a remand is necessary in order to obtain an addendum VA medical opinion that is compliant with the Board's remand instructions. Accordingly, this matter is REMANDED for the following action: Obtain an addendum opinion from a qualified examiner addressing the nature and etiology of the Veteran's indigestion. If the examiner determines that an examination, to include via telehealth, is necessary, one will be scheduled. The examiner is asked to provide a thoroughly reasoned opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's indigestion is due to or otherwise related to service. The examiner is to specifically address the Veteran's lay statements concerning symptoms experienced during service as well as after separation from service, including statements made during the September 2019 Board hearing. A complete rationale must be provided. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Gabrielle Ongies, 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.