Citation Nr: 21066718 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 17-60 958 DATE: November 2, 2021 REMANDED Service connection for irritable bowel syndrome (IBS) is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1988 to July 1992 and from February 2003 to January 2004. The Veteran provided testimony before the undersigned Veterans Law Judge (VLJ) at a June 2021 Board hearing. A complete transcript is of record. Service connection for IBS is remanded. The Veteran asserts that because of his deployment to Iraq, he developed IBS symptoms, to include diarrhea, constipation, bloody stool, and a raw rectum. Specifically, he asserts that while deployed, he ate expired Meals Ready to Eat (MREs) and consumed ice contaminated with feces. A review of the Veteran's service treatment records (STRs) does not appear to show any complaints or diagnosis for IBS or any other gastrointestinal conditions. For example, a Post-Deployment Health Assessment, shows that he denied having diarrhea. See STR dated November 12, 2003. The Veteran's treating physician provided a statement on March 1, 2016. The physician reported that the Veteran developed IBS from expired MREs. The Veteran's treating physician also provided a statement in August 2016. The physician noted the Veteran's deployment to Southwest Asia and that he began experiencing IBS symptoms on deployment. The physician reported that many soldiers, such as the Veteran, were put on quarters for days at a time due to this condition, throughout their time in Southwest Asia. The Veteran was afforded a VA examination in May 2016. The Veteran reported that he had diarrhea on average 3-4 days a week and on days he had diarrhea, he averaged 4 diarrheal stools. He also reported that on two occasions, he was not able to get to the bathroom in time and had some diarrhea on his underwear just before he sat down on the toilet. He also reported occasional constipation. After an in-person examination and a review of the Veteran's claims file, the examiner reported that it was unknown if the Veteran had IBS because he did not submit any records showing any diagnostic GI evaluation. The examiner explained that there were no medical records to exclude other possible conditions. Another VA medical opinion was provided in December 2017. After a review of the claims file, the examiner also found that there was insufficient evidence to diagnose IBS. The examiner explained that the Veteran has not had a complete GI workup to establish an etiology for his symptoms. The examiner reported that IBS was a diagnosis of exclusion and he had not had serologic testing, stool cultures, or testing for bacterial overgrowth. The Veteran testified at a hearing before the Board in June 2021 that he had lots of diarrhea when he was in Iraq. He reported that he told his first sergeant and commander about his stomach issues, as well as going to sick call. He also testified that when he came back from deployment, he still experienced symptoms, to include diarrhea, constipation, bloody stool, and a raw rectum. Upon his return, he started to see a private physician, who began treating him for IBS. He testified that while deployed, he was in a transportation unit and bought ice from Iraqis, but later found out that the ice contained feces. The VLJ informed the Veteran and his representative that the Veteran's private treatment records, showing that he was being treated for IBS in 2004, were not associated with the claims file. The Veteran reported that he would try to obtain the private records and associate them with the claims file. The record was held open for 30 days, so that the new evidence could be associated with the claims file. The Veteran also stated that he would attempt to get a new statement from his treating physician. The Veteran's treating physician provided a new statement in July 2021 in which he wrote that the Veteran had begun experiencing IBS difficulties from 2003, to the present. The physician explained that the Veteran was under a great deal of stress, which likely contributed to his IBS condition and he reported that the symptoms started while deployed. He reported that the Veteran's symptoms were diarrhea, constipation, a bloody rectum and loose stool. The Board finds that additional development is necessary to make a fully informed decision. The Board acknowledges the private medical opinions that the Veteran's treating physician has provided. However, the medical opinions have not used the correct, at least as likely as not, evidentiary standard. Further, the physician has not provided a rationale to support any of their opinions, has not indicated that he reviewed the Veteran's STRs, and there is no objective indication (or records to show) that the private physician had been treating the Veteran since his separation from the military. As such, the Board affords the provided nexus opinions very little probative weight. The Board also finds the May 2016 and December 2017 VA examinations to be inadequate. Although the Veteran was afforded a VA examination and has been provided two medical opinions regarding his IBS. The examiners have not undertaken the development they identified to render a diagnosis for IBS. As such, the Board finds that remand is necessary to provide the Veteran a new VA examination to provide the Veteran the proper diagnostic testing to ascertain which gastrointestinal conditions he is diagnosed with; and to provide an etiology opinion for any conditions that are identified. The Board also acknowledges the Veteran's assertion that he has experienced continuity of symptomatology of since his deployment to Iraq. However, his STRs do not support his assertion. In 2003, in his Post-Deployment Health Assessment, showed that he denied having diarrhea. See STR dated November 12, 2003. However, there may be outstanding STRs because there are only a few pages treatment notes from that time period. The Veteran also testified that within a month of returning from his deployment, he began seeing his private treating physician, who treats him for IBS. The Veteran testified that he would attempt to associate his private treatment records. However, the private treatment records do not appear to have been associated with the claims file. The Board also notes that the Veteran's VA treatment records begin in 2009, approximately five years after his separation from the military. The Board also notes that an alternative theory to entitlement has also been presented, that the Veteran's IBS may be secondary to his service-connected PTSD. See Buddy/Lay Statement dated October 30, 2017. He reported that multiple doctors have opined that his PTSD may cause IBS. As such, the Board finds that remand is necessary to obtain the Veteran's potentially outstanding STRs, to obtain the outstanding VA treatment records, to attempt to obtain his outstanding private treatment records, regarding his IBS treatment, and to obtain a VA medical opinion regarding secondary service connection. The Board acknowledges the Veteran's representative's assertion that he has provided enough evidence to show that service connection is warranted. However, as discussed, the treating physician's opinions have been afforded little probative value and the objective medical evidence of record does not corroborate the Veteran's assertion that he has experienced gastrointestinal issues since his deployment to Iraq. However, there may be outstanding STRs and private treatment records that do corroborate his assertions. Further, a new VA examination is also warranted so that the Veteran can undergo the appropriate diagnostic testing to ascertain what gastrointestinal conditions he may be diagnosed with; and to provide new medical opinions regarding both direct and secondary service connection. As such, the Board finds that additional development is necessary to ensure due process and a complete record upon which to decide the claim. 38 U.S.C. § 5103; 38 C.F.R. § 3.159. Accordingly, service connection for IBS is remanded. The matters are REMANDED for the following action: 1. Obtain the Veteran's service treatment records (STRs) from February 2003 to January 2004. 2. Obtain all outstanding VA treatment record from January 2004, forward, and associate them with the claims file. 3. Please request private treatment records from Dr. Irwin Plisco that pertain to the Veteran's IBS; and associate them with the claims file. 4. Schedule the Veteran for a VA examination for his gastrointestinal condition and obtain a medical opinion to address the etiology of the Veteran's IBS and/or any other gastrointestinal condition he is diagnosed with. The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater) that the Veteran's gastrointestinal condition either began during or was otherwise caused by his military service? Why or why not? (b) Is it as likely as not (50 percent or greater) that the Veteran's gastrointestinal condition was caused by his service-connected PTSD? Why or why not? (c) Is it as likely as not (50 percent or greater) that the Veteran's gastrointestinal condition was aggravated (made worse) by his service-connected PTSD. Why or why not? In providing the medical opinions as to secondary service connection, the examiner should address the relevance if any, of Dr. Plisco's statement that stress likely contributed to his IBS condition. See Medical Treatment Record Non-Government Facility received July 21, 2021. The examiner should also review the Veteran's testimony at his June 2021 Board hearing. If aggravation is found, the examiner should identify the baseline level of severity of the IBS by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the IBS. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Fu, 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.