Citation Nr: 21068662 Decision Date: 11/12/21 Archive Date: 11/12/21 DOCKET NO. 10-26 216 DATE: November 12, 2021 REMANDED Entitlement to service connection for a gastrointestinal disorder, to include gastroesophageal reflux disease (GERD), to include as secondary to service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1966 to February 1969. The Board thanks him for his service to our country. The Board previously remanded the issue on appeal in November 2014, June 2016, May 2017, February 2018 and March 2021. There has not been substantial compliance with the Board's March 2021 remand. Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for a gastrointestinal disorder, to include GERD, to include as secondary to service-connected disability, is remanded. The Board remands this issue to obtain an adequate VA medical opinion. A May 2021 VA negative medical opinion indicates that the Veteran's gastrointestinal disorder was not at least as likely as not aggravated beyond its natural progression by his service-connected low back disability or psychiatric disability. This is an incorrect standard for aggravation by service-connected disability. The correct standard, as clearly stated in the Board's March 2021 remand, is any increase in disability. In addition, the May 2021 VA negative medical opinion fails to address the December 2018 VA opinion provider's statement that "[m]edications... might contribute to constipation" as requested in the last remand instructions. The Board also observes that a September 2021 written brief presentation additionally asserts that the Veteran's service-connected posttraumatic stress disorder (PTSD) aggravates his gastrointestinal disorder. In support, the written brief presentation cites two studies. On remand, the agency of original jurisdiction (AOJ) should obtain a medical opinion that uses the correct standard for aggravation by service-connected disability, explains and addresses the December 2018 VA opinion provider's statement that "[m]edications... might contribute to constipation", and addresses the argument and articles in the September 2021 written brief presentation. Since the Board is remanding the claim, the AOJ should also update the Veteran's e-folder to include all outstanding VA treatment records. The matter is REMANDED for the following action: 1. Please obtain and associate with the Veteran's e-folder copies of all outstanding VA treatment records. 2. Then, after the foregoing records development is completed, please obtain an addendum VA medical opinion regarding the nature and etiology of the Veteran's gastrointestinal disorder, to include GERD. The AOJ should make the e-folder available to the clinician, and the examination report must reflect that the clinician reviewed it. If the clinician believes that a further examination (or telehealth interview, etc., if an in-person examination is not feasible) is necessary to answer the questions below, one should be scheduled. The clinician is asked to opine whether it is at least as likely as not that the Veteran's gastrointestinal disorder, to include GERD, is aggravated (defined as any increase in disability) by service-connected PTSD and/or degenerative disc disease, thoracolumbar spine, or any treatment/medication for PTSD and/or degenerative disc disease, thoracolumbar spine including in light of the December 2018 VA opinion provider's statement that "[m]edications... might contribute to constipation" and two articles: (1) Lee SP, Sung IK, Kim JH, Lee SY, Park HS, Shim CS., "The effect of emotional stress and depression on the prevalence of digestive diseases", J Neurogastroenterol Motil 2015;21:273-282 and (2) Van Oudenhove L, Crowell MD, Drossman DA, et al. "Biopsychosocial aspects of functional gastrointestinal disorders," Gastroenterology 2016;150:1355-1367, e2. The Board specifically advises the clinician that the Veteran has previously been diagnosed with GERD during the period on appeal. Therefore, even if the clinician finds no current gastrointestinal disability, the clinician should opine regarding the etiology of the previously diagnosed GERD. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level of disability (baseline) before the onset of the aggravation. The clinician should provide a complete rationale for any opinion offered. 3. Please confirm that the obtained VA medical opinion complies with this remand, specifically that the standard in the secondary aggravation opinion is any increase in disability, not the standard of beyond the natural progression as noted on the examination form itself. If not, obtain an addendum medical opinion using the correct standard. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Davitian, 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.