Citation Nr: 21008515 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 15-31 398 DATE: February 17, 2021 ORDER Entitlement to service connection for a chronic diarrhea, also claimed as irritable bowel syndrome (IBS), is granted. FINDINGS OF FACT 1. The Veteran served in the Southwest Asia theatre of operations during the Persian Gulf War. 2. Resolving all doubt in favor of the Veteran, his chronic diarrhea represents an undiagnosed illness related to his Persian Gulf War service. CONCLUSION OF LAW The criteria for entitlement to service connection for chronic diarrhea have been met. 38 U.S.C. §§ 1110, 1112, 1117, 5107; 38 C.F.R. §§ 3.303, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 2002 to November 2006. This matter comes before the Board of Veterans’ Appeals (Board) from an August 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The case was last before the Board in August 2018 and has returned to the Board for further appellate review. 1. Entitlement to service connection for a chronic intestinal disability The Veteran seeks service connection for an intestinal disability, which he asserts was caused by environmental exposures such as, DEET, pesticide treated uniforms, smoke from burning trash and feces in burn pits, and sand and dust, while serving in the Southwest Asia theater of operation, or alternatively, was caused or aggravated by his service-connected posttraumatic stress disorder (PTSD). Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Generally, to prove service connection there must be: (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). Additionally, under legislation specific to Persian Gulf War veterans, service connection may be established for a qualifying chronic disability resulting from an undiagnosed illness that became manifest during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more no later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). The term “qualifying chronic disability” means a chronic disability resulting from any of the following (or any combination of any of the following): (A) an undiagnosed illness; (B) a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under subsection (d) warrants presumptive service-connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i). Such chronic disability must not be attributed to any known clinical diagnosis by history, physical examination, or laboratory tests. 38 C.F.R. § 3.317(a)(1). Objective indications of a chronic disability include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. 38 C.F.R. § 3.317(a)(4). Manifestations of an undiagnosed illness may include, among other things, gastrointestinal signs or symptoms. 38 C.F.R. § 3.317(b)(10). Compensation shall not be paid, however, if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or events that occurred between the appellant’s most recent departure from active duty in the Southwest theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the appellant’s own willful misconduct or the abuse of alcohol or drugs. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(c). Service personnel records confirm that the Veteran served in the Southwest Asia theatre of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e); 38 U.S.C. § 101(33). Therefore, he qualifies for consideration for presumptive service connection for disabilities resulting from an undiagnosed illness or medically unexplained chronic multi-symptom illness. Service treatment records show that the Veteran denied currently having or suffering from diarrhea during deployment in a January 2004 post-deployment health assessment. In a September 2006 report of medical history, the Veteran denied any stomach, liver, intestinal trouble, or ulcer. Additionally, during a December 2006 VA general medical examination the Veteran denied nausea, vomiting, diarrhea, or constipation. The Veteran underwent a VA intestinal conditions examination in October 2015, wherein he reported that in 2012, he began needing to move his bowels immediately after eating. The examiner noted the Veteran’s report of experiencing watery diarrhea and taking antidiarrheal medication two to three times a week. She noted he underwent a colonoscopy in January 2013 that found no abnormalities. The examiner concluded that the Veteran did not have a diagnosis of an intestinal condition. After review of the evidence and examination of the Veteran, the examiner explained that as there is no objective evidence of an IBS diagnosis, she was unable to opine as to whether the Veteran’s claimed intestinal condition was related to service or his service-connected PTSD. In March 2019, the Veteran underwent a VA intestinal conditions examination, during which he reported that his symptoms began during his deployment and continued post-deployment. The examiner acknowledged the Veteran’s reported symptoms, but found that the Veteran did not have a currently diagnosed intestinal condition. The examiner explained that even though IBS may be considered a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, the Veteran’s work up by gastroenterology with diagnostic studies and other medical evidence did not reveal a diagnosis of IBS. The examiner further explained that the Veteran’s claimed condition is not un undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology or a diagnosable but medically unexplained chronic multi-symptom illness with a partially explained etiology. In an August 2020 addendum opinion, the examiner opined that the Veteran does not have an intestinal disability that is at least as likely as not proximately due to his service-connected PTSD and/or treatment thereof. The examiner explained that there is no objective clinical evidence to support a diagnosis of IBS and the Veteran’s claimed intestinal symptoms are not a chronic disability resulting from an undiagnosed illness or part of a medically unexplained chronic multi-symptom illness. As such, the examiner opined that the Veteran’s claimed intestinal disability is less likely than not related to service, to include environmental exposures such as exposure to DEET, pesticide treated uniforms, smoke from burning trash and feces in burn pits, and sand and dust during his active service in Southwest Asia. VA treatment records note a current active problem of diarrhea and irritable bowel, treated with antidiarrheal medication. He underwent a colonoscopy in January 2013 due to experiencing chronic diarrhea. The VA examiners have determined that the Veteran does not have a diagnosed disability to account for his symptoms. Thus, analysis of the Veteran's claim under the provisions of 38 C.F.R. § 3.317, pertaining to undiagnosed illnesses, is warranted. The regulatory provisions require only that the record establish objective indications of a chronic disability. Objective indications of a chronic disability include both "signs" in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(2)(ii)(3). In addition, gastrointestinal symptoms like diarrhea are specifically listed as manifestations of an undiagnosed illness capable of service connection. 38 C.F.R. § 3.317(b). As noted above, both the April 2010 and April 2013 VA examiners found that the Veteran's diarrhea was not found to be a symptom of a diagnosable disorder; this suggests that these symptoms could be the result of an undiagnosed illness. The Board finds that the Veteran is competent and credible to describe diarrhea as an objective indication of a chronic disability due to an undiagnosed illness. Indeed, the fact that medical professionals ordered a colonoscopy to address chronic diarrhea lends further credibility to the presence of the condition. The Board acknowledges that the VA examiners also opined that the symptoms were not an undiagnosed illness; however, that conclusion appears to be based on the lack of a diagnosis on gastrointestinal work-ups. Moreover, no etiology for the chronic diarrhea was provided. Accordingly, resolving all doubt in the Veteran’s favor, the Board finds that the competent and credible evidence is at least in equipoise as to whether the Veteran suffers from chronic diarrhea that manifested to a compensable degree at some point during the presumptive period under 3.317(a). See 38 C.F.R. § 4.114, Diagnostic Code 7319. Accordingly, service connection for chronic diarrhea as an undiagnosed illness associated with Persian Gulf War service is warranted. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Lance, 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.