Citation Nr: 21008357 Decision Date: 02/16/21 Archive Date: 02/16/21 DOCKET NO. 12-10 777 DATE: February 16, 2021 ORDER Service connection for Crohn’s disease is denied. FINDING OF FACT The preponderance of the evidence is against finding that Crohn’s disease began during active service, or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for Crohn’s disease have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1962 to May 1966. The case has been before the Board on several occasions. In July 2014, the Board found that new and material evidence had been received to reopen the issue of entitlement to service connection for Crohn’s disease, and remanded the underlying service connection claim for additional development. The case was again remanded in May 2017, December 2017, January 2019 and November 2020. All requested development has been accomplished and the case has been returned for further appellate consideration. Entitlement to service connection for Crohn’s disease The Veteran contends that service connection should be established for Crohn’s disease, which he believes had its onset during service. Specifically, it has been argued that he had gastrointestinal symptoms during service that marked the onset of this disease. It is also contended that the Crohn’s disease could have developed as secondary to service-connected cholecystectomy residuals. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). “When aggravation of a veteran’s non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation.” Allen v. Brown, 7 Vet. App. 439 (1995). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has had a diagnosis of Crohn’s disease during the appeal period, and evidence shows that he had gastrointestinal complaints during service and is service-connected for residuals of a cholecystectomy, the preponderance of the evidence weighs against finding that the Veteran’s Crohn’s disease began during service, is otherwise related to an in-service injury, event, or disease, or proximately due to or aggravated by a service-connected disability. Review of the record shows that the Veteran’s service treatment records (STRs) include complaints of gastrointestinal distress on several occasions during service. On examination for separation from service, in April 1966, it was noted that the Veteran had complaints of frequent indigestion caused by hyperacidity and gall stones since 1964 and was scheduled to undergo a cholecystectomy. A follow-up notation dated in May 1966 showed that the Veteran was doing well at the time of discharge from the hospital. On examination by VA in November 1966, the diagnosis was status post cholecystectomy. A VA examination dated in May 1971 showed that the Veteran was diagnosed with diarrhea of undetermined etiology and post cholecystectomy status, no significant post-cholecystectomy syndrome. A report of private hospitalization shows that the Veteran was hospitalized for reginal enteritis in December 1978. He underwent a resection of the terminal ileum and the right colon with end-to-end anastomosis, as well as other surgical procedures. A May 2003 VA examination noted that the Veteran had been diagnosed with Crohn’s disease in 1978. At that time, the diagnosis was Crohn’s disease. The examiner opined that the Veteran’s cholecystectomy did not cause or aggravate his Crohn’s disease. The rationale was that review of the medical literature showed that these were two separate disease processes “and neither one ha[d] affected the other.” A March 2011 colonoscopy performed as a follow-up to the Veteran’s Crohn’s disease diagnosis found no evidence of Crohn’s, inflammatory disease, polyps, tumors or diverticula. On examination by VA in September 2014, a VA examiner stated that an opinion regarding the etiology of the Veteran’s Crohn’s disease could not be rendered because, based on the findings of the March 2011 colonoscopy, there was no basis for a diagnosis Crohn’s disease. In an June 2017 addendum, the examiner was requested to render an opinion regarding whether the Veteran presently had Crohn’s disease or had had the disease at any time during the appeal period. It was opined that the claimed condition was less likely than not incurred in or caused by a claimed in-service injury, event or illness. The examiner then provided an explanation for the rationale of that opinion, which was based on a review of the Veteran’s STRs. After detailing the Veteran’s in-service gastrointestinal complaints, the examiner noted the Veteran’s arguments that he had been misdiagnosed in service and that the gastrointestinal symptoms were related to Crohn’s disease. This, the examiner explained, was not supported by the current medical literature. The examiner noted that the Veteran had not exhibited most of the common symptoms of Crohn’s disease throughout his military service. On the other hand, the examiner noted that the Veteran had exhibited the “classic symptoms for cholecystitis,” and that he was without the hallmark symptoms for Crohn’s disease. In addition, the Veteran was noted to have a normal colonoscopy in 2011. This procedure was considered to be the “Gold standard” for confirmation of a diagnosis of Crohn’s disease and there was not any evidence of this disease found. The examiner went on to note that the Veteran’s current problem list included Crohn’s disease in remission in October 2015, but that the Veteran was without nexus for Crohn’s disease and active military service. The examiner further observed that current medical literature did not support the establishment of such a claim. Regarding secondary service connection, the examiner stated that it was less likely than not that the Veteran’s cholecystectomy had caused or permanently aggravated the Crohn’s disease. The rationale was that the current medical literature did not support this claim as there was no correlation or causation with history of cholecystectomy and a positive history for Crohn’s disease. A November 2017 colonoscopy included an impression of mildly active Crohn’s disease with chronic scar tissue creating stenosis. An examination was conducted by VA in November 2019. At that time, the diagnosis was Crohn’s disease. After examination and review of the record, the examiner opined that this was less likely than not incurred in or caused by a claimed in-service injury, event, or illness. The rationale was that the Veteran had been diagnosed with Crohn’s disease many years after separation from service and that a search of the medical records during his time before and during service did not indicate symptoms consistent with Crohn’s disease. The same search was conducted for the period after service with no mention of abdominal distress until 1978, 12 years after service separation. The examiner noted that there had been documentation of several encounters in this period with no mention made of abdominal distress. The examiner went on to opine that the claimed condition was less likely than not proximately due to or the result of the Veteran’s service-connected condition. The rationale was that the two conditions were not medically related and were a separate entity from service-connected cholecystectomy, and that the medical literature did not support a medical relationship and a nexus had not been established. Regarding possible aggravation, the examiner stated that the Crohn’s disease was well controlled with exacerbation every other month. Therefore, the state of the Veteran’s disease process did not indicate any aggravation beyond its natural progression by the absence of a gallbladder. The examiner concluded that the Veteran’s Crohn’s disease was less likely related to his military service cholecystectomy or was aggravated beyond its natural progression. The Veteran’s records were reviewed again by a VA examiner in November 2020. Following review, the examiner opined that the Veteran’s claimed condition was less likely than not incurred in or caused by a claimed in-service injury, event, or illness. The rationale was that the Veteran’s in-service symptoms were the result of the in-service cholecystectomy and were unrelated to the current diagnosis of Crohn’s. Specifically, the examiner acknowledged that the Veteran displayed symptoms of loose stool and abdominal pain after his cholecystectomy and explained that these symptoms were complications from the cholecystectomy known as post-cholecystectomy syndrome. The examiner further explained that some people experienced symptoms similar to those caused by gallstones after surgery, including abdominal pain and diarrhea, and these were thought to be caused by bile leaking into areas such as the stomach, or by gallstones being left in the bile ducts. The examiner also addressed the Veteran’s reports in May 1971 of consistently experiencing diarrhea after meals and stated that this was unrelated to the current diagnosis of Crohn’s disease. Similarly, for the Veteran’s report that he had generalized abdominal pain and loose stools following the April 1966 cholecystectomy, the examiner also stated that these were unrelated to the current diagnosis of Crohn’s disease. Regarding secondary service connection, the examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veteran’s service-connected condition. The examiner explained that Crohn’s disease and a cholecystectomy were two completely separate disease processes with separate etiologies and there was no causal relationship between the two; a cholecystectomy did not cause Crohn’s disease. Regarding aggravation by the cholecystectomy residuals, the examiner stated that it was also less likely than not that the Crohn’s disease had been aggravated beyond natural progression by the cholecystectomy. As rationale, the examiner reiterated that these were separate disease processes with separate etiologies and that there was no causal relationship between the two. The examiner stated, “A cholecystectomy does not cause nor does it aggravate Crohn’s disease.” Taken together, the numerous VA opinions in the record establish that the Veteran’s Crohn’s disease is not at least as likely as not related to an in-service injury, event, or disease, and is not related in any way to a service-connected disability, including the residuals of a cholecystectomy. The examiners’ combined opinions are probative, because they are based on an accurate understanding of the Veteran’s medical history and provide an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran believes his Crohn’s disease is related to an in-service injury, event, or disease. He also believes it may be related to his service-connected cholecystectomy residuals. However, he is not competent to provide a nexus opinion regarding this issue. The questions involved in this case are medically complex, as they require knowledge of the interaction between multiple organ systems in the body. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the numerous combined opinions of the VA examiners. Significantly, there is no competent evidence, to include any medical opinions, to the contrary.   For these reasons, the Board finds that a preponderance of the evidence is against the Veteran’s claim for service connection for Crohn’s disease, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Joseph P. Gervasio 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.