Citation Nr: 21073990 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 15-04 277 DATE: December 13, 2021 REMANDED Entitlement to service connection for a gastrointestinal disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from September 1999 to October 2003. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. The issue on appeal was most recently before the Board in June 2021, when it was remanded to the agency of original jurisdiction (AOJ) for additional development. After taking further action, the AOJ confirmed and continued the prior denial and returned the case to the Board. See August 2021 Supplemental Statement of the Case (SSOC). Entitlement to service connection for a gastrointestinal disability is remanded. The Veteran contends that he is entitled to service connection for a gastrointestinal disability as due to his exposure to jet fuel during service. VA most recently obtained a medical opinion concerning his claim in July 2021; however, the Board finds that the examiner's opinion is incomplete as it did not address all of the relevant evidence of record in formulating the opinion. In a March 2021 opinion, the aforementioned examiner stated that the Veteran's history and service treatment records reflected an intestinal ailment that was ultimately diagnosed as a carcinoid tumor. The examiner indicated that the Veteran's records showed an onset of symptoms in 2011 and concluded that the eight-year period between his separation from service and his diagnosis made a nexus unreasonable. The examiner noted that the diagnosis of a carcinoid tumor was the only diagnosed gastrointestinal disorder that was relevant, as all other components of his complaint were subsumed by the condition. The examiner further noted that while the Veteran did have a historical repair of congenital gastroschisis, it was not wholly significant to his claim. The examiner concluded that exposure to and ingestion of jet fuel was not linked to carcinoid tumors, and research had not made a definitive link to any carcinogenic phenomenon. In a July 2021 addendum opinion, the examiner noted that carcinoid syndrome is caused by a carcinoid tumor, but stated that what caused carcinoid tumors is unclear. The examiner documented that the National Research Council (US) Subcommittee on Permissible Exposure Levels for Military Fuels concluded that the results of a 1996 study supported the hypothesis that the development of kidney cancer was more likely due to the exposure to aviation gasoline than the exposure to jet fuel, and that the only hematopoietic cancers reported in the study were non-Hodgkin's lymphoma (NHL), with no associations observed between exposures and NHL when adjusting for possible confounding factors. The examiner stated that a review of medical literature did not support the exposure to jet fuel as a causal factor for carcinoid tumors of the intestines, and no nexus was reasonable. While the examiner provided support for the conclusion that the Veteran's carcinoid tumors were not caused by his exposure to jet fuel, the Board finds that the examiner did not address all of the relevant evidence of record in stating that the Veteran's symptoms did not have an onset until 2011. The record reflects multiple instances during the Veteran's active duty service in which he made complaints of stomach or gastrointestinal problems. See, e.g., service treatment records dated in September 1999 (recurrent abdominal pain, weak stomach, bleeding from rectum); August 2002 (loose stools, abdominal pain). Although there are opinions of record indicating that these complaints represented acute conditions which resolved prior to his separation from service, the Board notes that the March and July 2021 examiner indicated that the Veteran's carcinoid tumor condition subsumed all other conditions that he was diagnosed with prior to his eventual diagnosis of a carcinoid tumor. Though this does not necessarily mean that the examiner intended to imply that all of the gastrointestinal symptoms which occurred prior to the diagnosis of a carcinoid tumor were due to that condition, it does present a need for clarification based on the other evidence of record. In a May 2011 VA gastrointestinal clinic note, the Veteran reported that he experienced nausea after eating since 2003, and that his pain started in approximately 2008. He stated that it was "crampy" in nature and had become worse over the prior year. Although there is no indication in the record that the Veteran has the education or training necessary to render a competent opinion regarding the etiology of his gastrointestinal disability, the Board notes that he is competent to report symptoms which are readily observable to a layperson, such as pain and stomach issues. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that a layperson is competent to identify observable symptoms). Given his history of gastrointestinal complaints during service, his report of recurring symptoms since his time in the military, and the examiner's conclusion that his other gastrointestinal diagnoses since at least 2011 were subsumed by his diagnosis of carcinoid tumors, the Board finds that remand is necessary for another addendum opinion which adequately addresses all of the relevant evidence of record. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate). This matter is REMANDED for the following action: 1. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 2. After the foregoing development has been completed, make arrangements to have the VA examiner who previously evaluated the Veteran in March 2021, and prepared an addendum in July 2021, review the record for purposes of preparing another addendum opinion. After reviewing the record, the clinician should clarify the prior opinions as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran has had a gastrointestinal disability at any time since October 2015 (when his claim for service connection was filed) that is attributable to service. The examiner is particularly asked to clarify whether it is at least as likely as not that the Veteran has had a gastrointestinal disability at any time since October 2015, including a carcinoid tumor, that had its onset in service. In doing so, the clinician should specifically consider and discuss the medical significance, if any, of service treatment records reflecting gastrointestinal complaints. See, e.g., service treatment records dated in September 1999 (recurrent abdominal pain, weak stomach, bleeding from rectum); August 2002 (loose stools, abdominal pain). The clinical should also consider and discuss the Veteran's statements regarding the onset and continuity of his symptoms prior to the diagnosis of a carcinoid tumor. If the prior examiner is no longer employed by VA or is otherwise unable to provide the opinion(s) requested, arrange to obtain the requested information from another qualified examiner. The need for another examination and/or telephonic or video interview of the Veteran is left to the discretion of the examiner selected to offer the requested opinions. A complete rationale for all opinions expressed must be provided. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issue on appeal should be readjudicated based on the entirety of the evidence. If the benefit sought remains denied, the Veteran and his representative should be issued a SSOC. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Ferguson, 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.