Citation Nr: 21076613 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 17-27 569 DATE: December 27, 2021 ORDER Entitlement to service connection for chronic fatigue syndrome (CFS) is granted. Entitlement to service connection for irritable bowel syndrome (IBS) is granted. FINDINGS OF FACT 1. The record evidence shows that the Veteran's chronic fatigue syndrome (CFS) is a qualifying chronic disability resulting from undiagnosed illness due to his Persian Gulf service. 2. The record evidence is at least in equipoise as to whether the Veteran has a chronic disability manifested by chronic fatigue and diagnosed as CFS which could be related to active service. 3. The record evidence shows that the Veteran's irritable bowel syndrome (IBS) is a qualifying chronic disability resulting from undiagnosed illness due to his Persian Gulf service. 4. The record evidence shows that the Veteran has a current diagnosis of IBS which manifested to a compensable degree during a 6-month period since service in Southwest Asia. CONCLUSIONS OF LAW 1. The criteria for service connection for chronic fatigue syndrome (CFS) have been met. 38 U.S.C. §§ 1110, 1117, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317 (2020). 2. The criteria for service connection for irritable bowel syndrome (IBS) have been met. 38 U.S.C. §§ 1110, 1117, 5107 (2018); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service September 1985 to October 1994, including in the southwest Asia theater of operations during the Persian Gulf War. This case comes before the Board of Veterans' Appeals (Board) on appeal from May 2016 and September 2016 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). Service Connection Chronic fatigue syndrome (CFS) The Veteran asserts that he has chronic fatigue which he attributes to his active service in Southwest Asia. He stated that after his service in the Persian Gulf, he experienced fatigue and that these symptoms have continued to the present. He stated that he has weekly prolonged attacks of completely debilitating fatigue, which last anywhere from 12 hours to 3 days. CFS and other conditions have made him unfit for work and general chores around the house. The Veteran contends that his CFS is related to service. He served on active duty in Southwest Asia Theater of operations from December 1990 to November 1991. Although the service treatment records do not show any evidence of fatigue, he asserts that he sought treatment for fatigue while in service. Several years after the first Gulf War, it was discovered that all of the records below the brigade level no longer existed. Thus, the Board finds the Veteran's statements concerning in-service incurrence of fatigue to be credible because they are consistent with the facts and circumstances of his service. The issue in this case essentially turns on whether the Veteran has a diagnosis of chronic fatigue syndrome which could be attributed to active service. Having reviewed the record evidence, the Board finds that the evidence is in relative equipoise as to whether the Veteran has been diagnosed as having CFS which is related to active service. In other words, there evidence both supporting and going against the Veteran's claim. The Board notes initially that, at the April 2016 Gulf War examination, he did not report any additional signs and/or symptoms that were not addressed through the completion of DBQ's regarding chronic fatigue syndrome, intestinal conditions, and fibromyalgia. The Board next notes that, at the April 2016 CFS examination, he was not diagnosed with CFS. He reported that he had chronic fatigue since service, which has worsened over time. He awakens feeling tired. On the weekends, he will stay in bed. He takes frequent naps and rest when not at work. He works a shortened day and uses telework. Upon physical examination, there was not any medicine required for control of chronic fatigue syndrome. The examiner noted that sleep apnea, anxiety, and fibromyalgia are etiologies for fatigue. There was no onset of CFS or debilitating fatigue that reduced the daily activity level. The Veteran did have symptoms attributable to CFS that includes debilitating fatigue, headaches, and sleep disturbance. He has cognitive impairment attributable to CFS that includes poor attention, inability to concentrate, forgetfulness, or other cognitive impairments. Constant fatigue, difficulty concentrating, and headaches were noted. The Veteran's symptoms due to CFS does restrict routine daily activities as compared to the pre-illness level. The symptoms restricted the routine daily activities to 50% to 75% of the pre-illness level. The symptoms do not result in periods of incapacitation. The examiner opined that the Veteran does not have an established diagnosis of CFS. The examiner noted the Veteran was diagnosed with fibromyalgia and the complaints of chronic fatigue were included in the fibromyalgia diagnosis. On the other hand, the July 2016 Veteran provided DBQ reflects that the Veteran was diagnosed with CFS. He reported that his fatigue began 25 years ago and has gotten progressively worse since that time. Upon physical examination, there was no continuous medication required for control of CFS. The examiner noted that other clinical conditions that may produce similar symptoms have been excluded by history, examination and/or laboratory test. There was an acute onset of CFS. The debilitating fatigue reduced daily activity level to less than 50% of pre-illness level. The Veteran had symptoms that include debilitating fatigue, low grade fever, nonexudative pharyngitis, muscle aches, fatigue lasting longer than 24 hours or longer after exercise, headaches, migratory joint pain, neuropsychologic symptoms, and sleep disturbance. He had cognitive impairment that includes forgetfulness, inability to concentrate, confusion, and poor attention. The symptoms are so severe as to restrict routine daily activities almost completely. There were periods of incapacitation of at least 6 weeks total duration per year. The CFS had an impact on his ability to work. An August 2016 private treatment record indicated that the Veteran was diagnosed with CFS. The Board finds that the Veteran is a "Persian Gulf War Veteran" who manifests a "qualifying chronic disability" (chronic fatigue syndrome or CFS) for presumptive service connection purposes. See 38 C.F.R. § 3.317 (a)(2)(i)(B)(2). As noted, the evidence is in relative equipoise as to whether he experiences current disability due to CFS which could be related to active service. On the one hand, the April 2016 VA examiner concluded that the Veteran did not have a diagnosis of CFS. On the other hand, the July 2016 VA examiner diagnosed the Veteran as having CFS along with the associated symptoms of debilitating fatigue, and cognitive impairments that include the inability to concentrate, forgetfulness, and/or confusion. The July 2016 examiner noted that the CFS symptoms were nearly constant and so severe as to restrict routine daily activities almost completely. Further, the examiner noted the Veteran has fatigue lasting longer than 24 hours after exercise and he has experienced periods of incapacitation at least 6 weeks total duration per year. In summary, and after resolving any reasonable doubt in the Veteran's favor, the Board finds that service connection for chronic fatigue syndrome on a presumptive basis is warranted. Irritable Bowel Syndrome (IBS) The Veteran asserts that he has irritable bowel syndrome (IBS) which he attributes to his active service in Southwest Asia. He stated that, after his service in the Persian Gulf, he experienced intermittent gastrointestinal symptoms. The symptoms became progressively worsened over the years. He asserts that he has alternating diarrhea and constipation. During the diarrhea periods, which averages 3 to 4 days, on average he has three to four explosive bowel movements per day. On his worst days, he has six to seven bowel movements a day. Further, he gets cramping pain in his lower abdomen. The cramping pains usually go away after a bowel movement only to later return when he needs another bowel movement. The service treatment records were negative for stomach, liver, and intestinal trouble regarding his enlistment and separation examinations, respectively. The records show that the Veteran had several bouts of diarrhea treated and resolved. Although the service treatment records do not show any evidence of IBS, the Veteran asserts that he sought treatment for his intestinal issues while in service. Several years after the first Gulf War, it was discovered that all of the records below the brigade level no longer existed. Thus, the Board finds the Veteran's statements concerning in-service incurrence of intestinal problems, to include IBS, to be credible because they are consistent with the facts and circumstances of his service. The issue in this case essentially turns on whether the Veteran has a diagnosis of irritable bowel syndrome (IBS) which is related to active service. At the April 2016 Gulf War examination, he did not report any additional signs and/or symptoms that were not addressed through the completion of DBQ's regarding chronic fatigue syndrome, intestinal conditions, and fibromyalgia. At the April 2016 VA examination, the examiner noted that the Veteran was diagnosed with diverticulitis. The Veteran reported that he had diarrhea during service. He further reported that since that time, he has developed alternating diarrhea and constipation. He indicated he will have loose stools with three to four bowel movements a day. He will then develop constipation with no bowel movements for two to three days. There is cramping and bloating during the constipation phase. He takes ex-lax or magnesium citrate for his lingering constipation. Upon physical examination, the Veteran does take continuous medication required for the intestinal disability. He had symptoms attributable to non-surgical non-infectious intestinal conditions that includes alternating diarrhea and constipation and abdominal distension. There are frequent episodes of bowel disturbance with exacerbations or attacks of the intestinal condition. He had seven or more exacerbations and/or attacks in the past twelve months. There has been loss of weight attributable to his intestinal disability. His intestinal disability impacted his ability to work. The examiner indicated that the Veteran's diverticulitis is a disease with a clear and specific etiology and diagnosis. The examiner opined that it is less likely as not related to the diarrhea and vomiting during service. It is less likely as not related to a specific exposure during service in Southwest Asia. Based on this history, there is no medical nexus for diverticulitis based on diarrhea and nausea which were acute viral episodes. There is no medical nexus for diverticulitis related to a specific exposure during service in Southwest Asia. In addition, the Veteran was diagnosed recently with fibromyalgia which included many of his intestinal complaints. At the April 2016 VA examination, the examiner noted that the Veteran did not have any stomach or duodenum disabilities. The Veteran reported that he developed nausea, vomiting, and abdominal cramping during active-duty service in 1991 while deployed to the Gulf region. He has severe cramping pain with syncope. Upon physical examination, the Veteran's treatment plan included taking continuous medication for his diagnosed condition. He has four or more symptom recurrences per year, lasting less than one day. He has four or more episodes of severe symptoms. The abdominal pain occurs less than monthly. He has periodic nausea one time a year, less than one day. He has recurrent vomiting four or more times per year, lasting less than a day. There are incapacitating episodes due to the stomach or duodenum disabilities. Incapacitating episodes are described as severe pain with dizziness and syncope. There were four or more incapacitating episodes lasting less than a day. The stomach disability does not impact his ability to work. The examiner indicated that the Veteran's stomach cramps, nausea, and vomiting are an undiagnosed condition. Base on the history, there is no established stomach diagnosis. In addition, the Veteran was diagnosed recently with fibromyalgia which included many of his stomach complaints. A June 2016 private treatment note shows the Veteran presented with intermittent bloating that causes cramps. He indicates that he often will feel sweaty and turn pale. He has syncope issues. The examiner noted that he has reassured the Veteran that he will check celiac antibodies, as well as stool for HP antigen, ova, and parasites, fecal fat, and C diff. He stated if the above are negative, he would feel comfortable with an IBS diagnosis unless the Veteran were to have a change status. A July 2016 private treatment note reflects a diagnosis of IBS. The examiner noted that the Veteran still complains of nausea and diarrhea. Completed course for H pylori. C diff was negative. In the present case, the Veteran served in the Southwest Asia Theater of Operations during the Gulf War as shown by service personnel records. Thus, the Board finds that the Veteran is a "Persian Gulf Veteran" for the purposes of 38 C.F.R. § 3.317. See 38 C.F.R. § 3.317 (e)(1). Additionally, the Veteran currently has a diagnosis of IBS which is a qualifying chronic disability for purposes of 38 U.S.C. § 1117. See 38 C.F.R. § 3.317 (a)(2)(i)(B)(3). The Veteran's IBS has manifested to a compensable level. The Board has analyzed the Veteran's reported symptoms of IBS under Diagnostic Code (DC) 7319 (Irritable Colon Syndrome). See 38 C.F.R. § 4.114, DC 7319. This DC provides a 10 percent rating for moderate irritable colon syndrome symptoms with frequent episodes of bowel disturbance with abdominal distress. Here, during the April 2016 VA examination, the Veteran reported alternating diarrhea and constipation. He further reported that he will have loose stools with three to four bowel movements a day that lasts four to five days. He would then develop constipation with no bowel movements for two to three days. He had frequent abdominal distension that includes frequent burping and farting. The Veteran experienced seven or more exacerbations of severe cramping with constipation in the past twelve months. The Board finds that this evidence shows that the Veteran meets the criteria for a compensable rating under DC 7319. Although the April 2016 examiner did not diagnose the Veteran with IBS, he was diagnosed two months later with IBS complaining about the same intestinal issues. IBS like diverticulitis has its separate etiology. The medical evidence shows that the Veteran reported his symptoms during the appeal period. He is competent to report his bowel issues. Accordingly, and after resolving any reasonable doubt in favor of the Veteran, the Board finds that the currently diagnosed irritable bowel syndrome has been present to a disabling (at least 10 percent) degree within the applicable period following his Persian Gulf War service in the Southwest Asia and, as such, service connection for IBS on a presumptive basis is warranted. MICHAEL T. OSBORNE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Ivan Franklin 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.