Citation Nr: 21074409 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 16-18 538 DATE: December 15, 2021 REMANDED Entitlement to service connection for a gastrointestinal disorder, to include stomach ulcers, and as secondary to the service-connected posttraumatic stress disorder (PTSD) and/or migraines, is remanded. REASONS FOR REMAND The Veteran had served on active duty in the United States Army from August 2001 to December 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2019, the Veteran presented testimony before the undersigned Veterans Law Judge, and a copy of the transcript is of record. This matter was previously remanded in February 2020 for further development. The matter returns for appellate consideration. Entitlement to service connection for a gastrointestinal disorder, to include stomach ulcers, and as secondary to the service-connected PTSD and/or migraines, is remanded. The Veteran contends that his gastrointestinal disorder is directly related to service, to include as secondary to the service-connected PTSD and/or migraines. See September 2020 Third Party Correspondence. Pursuant to the February 2020 Board remand, a May 2020 VA examination was provided. The examination report reflected a diagnosis for irritable bowel syndrome (IBS), including symptoms of abdominal distension and diarrhea/constipation. The examiner provided negative nexus opinions on both a direct and secondary basis. With regard to direct service connection, the examiner concluded that there is no objective evidence of any stomach ulcers or gastrointestinal condition diagnosed in service records or upon separation, and that the Veteran's PUD noted in 2012 and IBS in 2015 both occurred many years following service; therefore, a nexus had not been established. With regard to secondary service connection, the examiner concluded that stomach ulcers and PTSD are two separate medical conditions, and that medical literature did not support a causal relationship between the two. In addition, the examiner indicated that peptic ulcers are usually caused by bacterium Helicobacter pylori (H. pylori) and long-term use of NSAIDs, and that stress and spicy foods do not cause peptic ulcers. Lastly, the examiner concluded that there is no evidence to support aggravation beyond natural progression by the service-connected PTSD and that the Veteran is maintained on omeprazole for his stomach ulcer/PUD and metamucil/lactulose for IBS. In September 2020 correspondence, the Veteran and his representative asserted that there were several inadequacies in the May 2020 VA examination, to include improper medical qualification in gastrointestinal disorders of the examiner (who is noted as a physician assistant), inadequate rationales in support of the examiner's opinions, and improper diagnostic testing to account for all possible gastrointestinal disorders including GERD, peptic ulcers, dyspepsia, and "numerous tiny low attenuation lesions within bilateral hepatic lobe" along with "small periumbilical hernia." Additionally, the Veteran asserted that his gastrointestinal condition had its onset during his in-service theater tour in Iraq around 2003. The Board finds the May 2020 VA examination is inadequate. First, the examiner relies solely on the absence of service treatment records to conclude the lack of a nexus between the Veteran's gastrointestinal disability and military service. Dalton v. Nicholson, 21 Vet. App. 23, 40 (2007); see also Smith v. Derwinski, 2 Vet. App. 137, 140 (1992). Second, the examiner failed to address whether the Veteran's gastrointestinal disability is caused or aggravated by the service-connected migraines. Lastly, the examiner failed to provide a sufficient rationale in support of the aggravation opinion by the service-connected PTSD. Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the Board confers the right to compliance with remand orders). The matter is REMANDED for the following actions: 1. Schedule the Veteran for a VA examination by a qualified clinician specializing in gastrointestinal disorders to determine the nature and etiology of the claimed gastrointestinal disability. The claims folder and a copy of this remand in its entirety must be provided to the examiner in conjunction with the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and lay statements; the examiner must indicate on the examination report that such review was undertaken. The examiner must determine: (a) all of the Veteran's current gastrointestinal disorders, to specifically determine whether he has had stomach ulcers during the appeal period. (b) whether it is at least as likely as not (50 percent probability or more) that the Veteran's currently diagnosed gastrointestinal disorders are proximately due to his service-connected PTSD and/or migraines, or (c) whether the Veteran's gastrointestinal disorders are aggravated by his service-connected PTSD and/or migraines. The examiner is advised that secondary service connection does not require "permanent" worsening of the condition being claimed by the service-connected disability and requires considering whether there has been any worsening, no matter how incremental, so even if not above and beyond the condition's natural progression. See Ward v. Wilkie, 31 Vet. App. 233 (2019). The clinician must provide separate findings and rationales relating to causation and aggravation. Atencio v. O'Rourke, 30 Vet. App. 74 (2018). (d) The examiner must also address whether it is at least as likely as not (50 percent probability or more) that any of the Veteran's claimed gastrointestinal disorders had its onset during service or is otherwise related to the Veteran's active service. The examiner should consider the Veteran's reports for a diagnosis of GERD, dyspepsia, peptic ulcers, and "numerous tiny low attenuation lesions within bilateral hepatic lobe" along with "small periumbilical hernia." The examiner must provide a rationale in support of all opinions provided. If any opinion cannot be provided without resorting to speculation, the examiner must explain why this is so. 2. Then, readjudicate the Veteran's claim on appeal. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided a supplemental statement of the case. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Y. Asfaw, 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.