Citation Nr: 21075001 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 16-39 081 DATE: December 17, 2021 REMANDED Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected stricture of the esophagus, and as due to undiagnosed illness or chronic multi-symptom illness, is remanded. Entitlement to service connection for hiatal hernia, to include as secondary to service-connected stricture of the esophagus, and as due to undiagnosed illness or chronic multi-symptom illness, is remanded. Entitlement to service connection for anal fissures, to include as secondary to service-connected irritable bowel syndrome (IBS), and as due to undiagnosed illness or chronic multi-symptom illness, is remanded. Entitlement to service connection for hemorrhoids, to include as secondary to service-connected IBS, and as due to undiagnosed illness or chronic multi-symptom illness, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from June 1990 until his honorable discharge in June 1994. The Veteran served in the Southwest Asia theater of operations in support of Operation Desert Shield/Storm and Operation Southern Watch. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). These matters were previously before the Board in August 2018 and June 2020. Most recently, in June 2020, the Board remanded entitlement to service connection for (1) a gastrointestinal condition, to include gastritis and constipation, to include as due to undiagnosed illness or chronic multi-symptom illness, (2) hiatal hernia and gastroesophageal reflux disease (GERD), to include as due to an undiagnosed illness or chronic multi-symptom illness, (3) peptic stricture, to include as due to an undiagnosed illness or chronic multi-symptom illness, and (4) anal fissures or hemorrhoids, to include as due to an undiagnosed illness or chronic multi-symptom illness. A September 2021 rating decision granted service connection for IBS, with an evaluation of 30 percent effective July 9, 2013, and stricture of the esophagus, with an evaluation of 0 percent effective July 9, 2013. The issues of entitlement to service connection for GERD, hiatal hernia, anal fissures, and hemorrhoids remain before the Board. See AB v. Brown, 6 Vet. App. 35 (1993). For the reasons discussed below, the Board finds there was not substantial compliance with the June 2020 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Remand is necessary to obtain adequate and well-reasoned opinions. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. 1. Entitlement to service connection for GERD is remanded. 2. Entitlement to service connection for hiatal hernia is remanded. The Veteran is seeking service connection for GERD, also claimed as acid reflux. See July 2014 VA Form 21-526EZ. Specifically, he contends his GERD stems from military service in the Gulf War area. See January 2016 VA Form 9. In August 2018, the Veteran's appeal as to service connection for GERD was expanded to include entitlement to service connection under the theory of as due to undiagnosed illness; in June 2020, the Veteran's appeal was expanded to include entitlement to service connection for hiatal hernia. In its June 2020 remand, the Board directed the Agency of Original Jurisdiction (AOJ) to obtain an examination and medical opinion to determine whether the Veteran's GERD and hiatal hernia began in service, was caused by service, or is otherwise related to service, to include his conceded exposure to a toxic environment (whether specified or unspecified) during service in the Southwest Asia theater of operations or otherwise; whether the Veteran has an undiagnosed illness consisting of GERD and/or hiatal hernia; and whether the Veteran has a chronic multi-symptom illness consisting of a cluster of signs and symptoms of one or more functional (but not structural) gastrointestinal disorders. The Veteran was afforded a QTC Esophageal Conditions examination in June 2021. The QTC examiner diagnosed GERD, hiatal hernia, and stricture of the esophagus. The examiner noted the following signs or symptoms due to esophageal conditions: dysphagia, pyrosis, reflux, regurgitation, substernal pain, and sleep disturbance. The examiner noted the Veteran's esophageal stricture was "mild" in severity, with dysphagia and substernal pain. The examiner provided an opinion as to direct service connection and as to an undiagnosed chronic multi-symptom illness. The Board finds the direct service connection opinion was inadequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). As to the direct-service connection opinion, the examiner opined the Veteran's GERD and hiatal hernia were less likely than not incurred in service, to include his conceded exposure to a toxic environment during service in the Southwest Asia theater of operations. As supporting rationale, the examiner reasoned there are no service treatment records (STRs) which demonstrate a diagnosis or treatment for GERD and/or hiatal hernia during service. An examiner may not merely list facts and conclusions with no reasoned explanation for connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 298 (2008). The examiner did not explain why the lack of in-service treatment, and diagnosis of GERD and hiatal hernia many years following service (1996 (GERD), 2018 (hiatal hernia)), was of consequence to the opinion. Additionally, the issue of entitlement to service connection for GERD and hiatal hernia, to include as secondary to his now service-connected stricture of the esophagus has been raised by the evidence. The Board is required to consider all theories of entitlement to service connection. Szemraj v. Principi, 357 F.3d 1370 (Fed. Cir. 2004). Remand is necessary to fulfill VA's duty to assist. 38 U.S.C. § 5103A; Stefl v. Nicholson, 21 Vet. App. 120 (2007). 3. Entitlement to service connection for anal fissures is remanded. The Veteran is seeking service connection for anal fissures. See July 2014 VA Form 21-526EZ. Specifically, he contends his anal fissures stem from military service in the Gulf War area. See January 2016 VA Form 9. In August 2018, the Veteran's appeal as to service connection for anal fissures was expanded to include entitlement to service connection under the theory of as due to undiagnosed illness. In its June 2020 remand, the Board directed the AOJ to obtain an examination and medical opinion to determine whether the Veteran's anal fissures began in service, or are otherwise related to service, to include his conceded exposure to a toxic environment (whether specified or unspecified) during service in the Southwest Asia theater of operations or otherwise; whether the Veteran has an undiagnosed illness consisting of anal fissures; and whether the Veteran has a chronic multi-symptom illness consisting of a cluster of signs and symptoms of one or more functional (but not structural) gastrointestinal disorders. The Veteran was afforded a QTC Rectum and Anus Conditions examination in June 2021. During the examination, the Veteran stated the condition began with itching, and pain during bowel movements. He reported the condition has stayed the same. His treatment plan included Colace and Preparation H. The QTC examiner diagnosed internal or external hemorrhoids. The examiner provided an opinion as to direct service connection and as to an undiagnosed chronic multi-symptom illness. The Board finds the direct service connection opinion was inadequate. Barr, 21 Vet. App. 303. As to the direct-service connection opinion, the examiner opined it is less likely than not the Veteran's anal fissures are related to the Veteran's military service, to include his conceded exposure to a toxic environment during service in the Southwest Asia theater of operations or otherwise. As supporting rationale, the examiner reasoned there are no findings, signs and/or symptoms to support a diagnosis of anal fissures. The Board finds the June 2021 examination reflects a less than thorough review of the evidence. The Veteran's treatment records include a diagnosis and treatment for anal fissures. The June 2021 examiner did not provide an etiological opinion for this diagnosis. Additionally, the issue of entitlement to service connection for anal fissures, to include as secondary to his now service-connected IBS, has been raised by the evidence. The Board is required to consider all theories of entitlement to service connection. Szemraj, 357 F.3d 1370. Remand is necessary to fulfill VA's duty to assist. 38 U.S.C. § 5103A; Stefl, 21 Vet. App. 120. 4. Entitlement to service connection for hemorrhoids is remanded. The Veteran is seeking service connection for hemorrhoids. See July 2014 VA Form 21-526EZ. Specifically, he contends his hemorrhoids stem from military service in the Gulf War area. See January 2016 VA Form 9. In August 2018, the Veteran's appeal as to service connection for anal fissures was expanded to include entitlement to service connection under the theory of as due to undiagnosed illness; in June 2020, the Veteran's appeal was expanded to include entitlement to service connection for anal fissures or hemorrhoids. In its June 2020 remand, the Board directed the AOJ to obtain an examination and medical opinion to determine whether the Veteran's hemorrhoids began in service, was caused by service, or is otherwise related to service, to include his conceded exposure to a toxic environment (whether specified or unspecified) during service in the Southwest Asia theater of operations or otherwise; whether the Veteran has an undiagnosed illness consisting of hemorrhoids; and whether the Veteran has a chronic multi-symptom illness consisting of a cluster of signs and symptoms of one or more functional (but not structural) gastrointestinal disorders. The Veteran was afforded a QTC Rectum and Anus Conditions examination in June 2021. During the examination, the Veteran stated the condition began with itching, and pain during bowel movements. He reported the condition has stayed the same. His treatment plan included Colace and Preparation H. The QTC examiner diagnosed internal or external hemorrhoids. The examiner provided an opinion as to direct service connection and as to an undiagnosed chronic multi-symptom illness. The Board finds the direct service connection opinion was inadequate. Barr, 21 Vet. App. 303. As to the direct-service connection opinion, the examiner opined the Veteran's hemorrhoids were less likely than not incurred in service, to include his conceded exposure to a toxic environment during service in the Southwest Asia theater of operations. As supporting rationale, the examiner reasoned there are no STRs which demonstrate a diagnosis or treatment for hemorrhoids during service. An examiner may not merely list facts and conclusions with no reasoned explanation for connecting the two. Nieves-Rodriguez, 22 Vet. App. 298. The examiner did not explain why the lack of in-service treatment, and diagnosis of hemorrhoids many years following service (March 2012), was of consequence to the opinion. Additionally, the issue of entitlement to service connection for hemorrhoids, to include as secondary to his now service-connected IBS, has been raised by the evidence. The Board is required to consider all theories of entitlement to service connection. Szemraj, 357 F.3d 1370. Remand is necessary to fulfill VA's duty to assist. 38 U.S.C. § 5103A; Stefl, 21 Vet. App. 120. The matters are REMANDED for the following action: 1. Afford the Veteran an opportunity to submit or identify any outstanding pertinent evidence that are not already associated with the claims file. The AOJ should attempt to obtain those records if the appropriate authorization is provided. If any records sought are not available, the Veteran and his representative should be notified. 2. Obtain any outstanding VA medical records. 3. After the above is completed, obtain an addendum opinion by an appropriate clinician to determine the nature and etiology of the Veteran's GERD, hiatal hernia, anal fissures, and hemorrhoids. If further examination of the Veteran is deemed necessary for the opinion sought, such should be arranged. The Veteran's claims file and a copy of this Remand should be provided to the examiner. Following review of the record, the examiner is asked to provide an opinion as to the following: (a.) Whether it is at least as likely as not (50 percent probability or greater) the Veteran's GERD had its onset in or is otherwise related to his active duty service, to include his exposure to a toxic environment in the Southwest Asia theater of operations. (b.) Whether it is at least as likely as not the Veteran's hiatal hernia had its onset in or is otherwise related to his active duty service, to include his exposure to a toxic environment in the Southwest Asia theater of operations. (c.) Whether it is at least as likely as not the Veteran's anal fissures had its onset in or is otherwise related to his active duty service, to include his exposure to a toxic environment in the Southwest Asia theater of operations. (d.) Whether it is at least as likely as not the Veteran's hemorrhoids had its onset in or is otherwise related to his active duty service, to include his exposure to a toxic environment in the Southwest Asia theater of operations. Note (1): The examiner should address the Veteran's competent lay statements regarding onset, in-service incurrence, and continuity of symptomatology since service separation. Note (2): While an absence of in-service complaints or treatment may be considered, the absence of such should not form the sole basis of a negative opinion. (e.) Whether it is at least as likely as not the Veteran's GERD and/or hiatal hernia is: Proximately due to the Veteran's service-connected stricture of the esophagus, or Aggravated beyond its natural progression by the Veteran's stricture of the esophagus. Note (1): "permanent worsening" or increase in severity is not required to demonstrate aggravation. Note (2): If aggravation is found to exist, the examiner should provide an assessment, if possible, of the baseline level of impairment of the GERD and/or hiatal hernia prior to aggravation. The clinician should then provide a quantification, if possible, of the level of additional impairment above and beyond its baseline level imposed by the service-connected stricture of the esophagus. (f.) Whether it is as least as likely as not the Veteran's anal fissures and hemorrhoids are: Proximately due to the Veteran's service-connected IBS, or Aggravated beyond its natural progression by the Veteran's IBS. Note (1): "permanent worsening" or increase in severity is not required to demonstrate aggravation. Note (2): If aggravation is found to exist, the examiner should provide an assessment, if possible, of the baseline level of impairment of the anal fissures and/or hemorrhoids prior to aggravation. The clinician should then provide a quantification, if possible, of the level of additional impairment above and beyond its baseline level imposed by the service-connected IBS. TESS WINKLER Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Grace Johnk, 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.