Citation Nr: 21008268 Decision Date: 02/12/21 Archive Date: 02/12/21 DOCKET NO. 12-17 040 DATE: February 12, 2021 REMANDED Entitlement to service connection for a gastrointestinal (GI) disability, to include as secondary to left hip and pelvic osteoarthritis, lumbosacral strain, and bipolar disorder, is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from March 2004 to May 2004. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a November 2011 rating decision which, in relevant part, denied service connection for a gastrointestinal condition, to include gallstones. In November 2014, March 2016, August 2017, May 2018, and May 2020, the case was remanded for additional development. [Notably, the May 2018 Board decision denied service connection for a left hip disability. The Veteran appealed that decision to the U.S. Court of Appeals for Veterans Claims (CAVC), resulting in a September 2019 Memorandum Decision which reversed the Board’s finding that the presumption of soundness had been rebutted, vacated the decision, and remanded the matter for proceedings consistent with the Memorandum Decision. Subsequently, the May 2020 Board decision granted service connection for left hip osteoarthritis and pelvic osteoarthritis, lumbosacral strain, and bipolar disorder. Consequently, those matters are not before the Board.] Entitlement to service connection for a GI disability, to include as secondary to left hip and pelvic osteoarthritis, lumbosacral strain, and bipolar disorder The Board is aware that this case is long-pending, and regrets the delay inherent with yet another remand. However, further development of the medical evidence is necessary to properly adjudicate the claim. The Veteran’s primary theory of entitlement in this matter is one of secondary service connection. See May 2011, September 2012, and November 2019 statements. On January 2017 VA examination, he denied any known connection between cholecystitis and his military service. The examiner opined that the Veteran’s gallbladder removal/cholecystitis was less likely than not caused by psychiatric medication because he “does not take any psych meds for any service connected conditions.” That opinion is based on an inaccurate factual premise (particularly in light of the May 2020 Board decision, which granted service connection for bipolar disorder), as the record shows the Veteran has taken psychiatric and pain medications such as bupropion, cyclobenzaprine hcl, hydrocodone, lamotrigine, lisdexamfetamine (Vyvanse), naproxen, and zolpidem. See August 5, 2013 VA treatment record. The opinion also did not address aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-141 (2013). In May 2020, the Board remanded this matter for an adequate medical opinion. On October 2020 VA (fee basis) stomach and duodenal conditions, and gallbladder and pancreas conditions examinations, the physician examiner opined that the Veteran’s gallbladder condition is less likely as not proximately due to or the result of service, and less likely as not proximately due to or aggravated by his bipolar disorder, lumbar strain, and left hip disability. The did not address the possibility of a nexus between the Veteran’s GI disability and medications prescribed for his bipolar disorder, lumbar spine, and left hip disabilities. He also failed to address a journal article (received in November 2019) regarding possible mechanisms for digestive problems in military veterans, including a notation that “psychological factors such as depression and anxiety play some role in the pathogenesis of functional gastrointestinal disease.” [As noted above, a May 2020 Board decision granted service connection for bipolar disorder.] Remand for an addendum opinion which fully addresses this theory and the submitted journal article is necessary. The matter is REMANDED for the following: 1. Obtain all outstanding (updated to the present) records of VA evaluations and treatment the Veteran has received for GI disability(ies) or complaints. 2. Then, arrange for the Veteran’s record to be forwarded to the October 2020 VA (fee basis) gallbladder and pancreas conditions examiner for review and an addendum advisory medical opinion regarding the likely etiology of his GI disability. [If that provider is unavailable or unable to provide the opinion sought, arrange for the record to be forwarded to another appropriate clinician for review and the opinion sought. If further examination is deemed necessary, such should be arranged.] On review of the complete record (specifically including this remand, the journal article received in November 2019 regarding possible mechanisms of GI problems, the October 2020 examination reports, and any records received pursuant to the development ordered above), the examiner should provide an addendum opinion that responds to the following: Is it at least as likely as not (a 50% or better probability) that the Veteran’s GI disability, to include cholecystitis, has been caused or aggravated by his service-connected left hip osteoarthritis and pelvic osteoarthritis, lumbosacral strain, and bipolar disorder, to include as due to medication prescribed for treatment of such disabilities? The opinion must address aggravation. The rationale provided must discuss the effects of the medications prescribed for the Veteran’s service-connected disabilities and the submitted literature indicating that “psychological factors such as depression and anxiety play some role in the pathogenesis of functional gastrointestinal disease.” All opinions must include rationale with citation to supporting factual data and medical principles (with citation to medical literature, as deemed appropriate). GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Dupont, 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.