Citation Nr: 21009240 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 17-47 446 DATE: February 22, 2021 ORDER The claim of entitlement to service connection for a chronic gastrointestinal (GI) disorder, to include chronic diarrhea and/or irritable bowel syndrome (IBS) with bowel urgency, is denied. FINDING OF FACT The probative medical evidence of record weighs against finding that the Veteran has a current GI disorder, to include chronic diarrhea and/or IBS with bowel urgency, related to his military service. CONCLUSION OF LAW The criteria for service connection for a GI disorder, to include chronic diarrhea and/or IBS with bowel urgency, have not been met. 38 U.S.C. § 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1955 to November 1957. In April 2019, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge; a transcript of that hearing is of record. This case was remanded in April 2019 and October 2020 for further development. In this case, in May 2013 and October 2017, the National Personnel Records Center (NPRC) informed the Veteran that his complete service treatment records (STR’s) and military personnel records (MPRs) were fire-related and were not available. All available STRs and MPR, however, were associated with the claim file. In cases where records once in the hands of the government are lost, the Board has a heightened obligation to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule. O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board’s analysis has been undertaken with this heightened duty in mind. The case law does not, however, lower the legal standard for proving a claim for service connection, but rather increases the Board’s obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the Veteran. Russo v. Brown, 9 Vet. App. 46 (1996). In this case, it appears that the pertinent STRs and MPRs have been obtained or reconstructed from other sources and are available for review. Entitlement to Service Connection for a Chronic GI Disorder, to Include Chronic Diarrhea with Bowel Urgency, and/or IBS. Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained in the line of duty during active military service. 38 U.S.C. § 1131 (2012); 38 C.F.R. § 3.303(a) (2019). Service connection may be granted for a disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d) (2019). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). Service connection may also be established with certain chronic diseases based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1110, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2019). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When a claimant seeks benefits and the evidence for and against the claim is in relative equipoise, the claimant prevails. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for a claim to be denied. Alemany v. Brown, 9 Vet. App. 518 (1996). The STRs reflect that the Veteran was hospitalized from September 27, 1956, and discharged on November 30, 1956. He was treated for a pilonidal cyst for which service connection has been granted. The Veteran was also seen in January 1957 with acute gastroenteritis manifested by nausea and diarrhea which had been present for one day. Medication was prescribed and he felt better the next day. He was returned to duty two days later. He was hospitalized from August 12, 1957, to September 10, 1957. On admission, he complained of headaches, chills, and fever. He also experienced anorexia and vomiting and slight left lower quadrant pain. During the first two weeks of hospitalization, he had rather marked myalgia. The spleen and liver remained palpable, but the cervical nodes gradually decreased. He was feeling fairly well by August 29, when he noted onset of an upper respiratory infection (URI) with cough, sore throat, and fever. There was slight abdominal pain without urinary symptoms. By September 5, the spleen was only minimally palpable with the liver no longer palpable, and the respiratory condition had subsided. He was free from fever from September 5 and was discharged shortly thereafter. It was felt “very likely” that he had had infectious mononucleosis, but this diagnosis was not conclusively proven. The Veteran’s separation examination, dated on September 10, 1957, includes a summarization of the above treatment. VA examination testing in November 1957 included an upper GI tract study with small bowel study and barium enema study, all of which were within normal limits. In March 2012, the Veteran filed his initial claim for service connection for bowel syndrome, noting that the disorder was first noted in 1957 when hospitalized during service. He said that within minutes of eating, he immediately experienced a bowel movement. This continued to the present day and was precipitated by breaking out into a sweat. When examined by VA in June 2012, it was opined that the claimed condition of bowel incontinence was less likely than not (less than 50 percent probability), incurred in or caused by the claimed in-service injury, event, or illness. For rationale, the examiner noted that the Veteran gave a history of being hospitalized during service for malaria symptoms and that he developed bowel incontinence. The examiner reviewed the record and stated that it appeared that the Veteran was admitted for pyelonephritis and while in the hospital, he developed an URI. During the September 1957 hospitalization, there was no mention of bowel incontinence. It was also noted that prior treatment during service for gastroenteritis was noted, but that his symptoms resolved with no further issues noted. The examiner found no other documentation of bowel incontinence or bowel urgency in the claim file. A complete physical examination was conducted in March 2011. No chronic GI problems were noted, and a “review of symptoms” noted that he was negative for abdominal pain, constipation, and diarrhea. A July 2013 barium enema showed a small hiatal hernia and gastroesophageal reflux (GERD) to the cervical esophagus. There is report of left abdominal pain in 2014, but no significant findings were seen upon acute abdominal series. When being monitored for his diabetes in March 2015, his “review of symptoms” again noted that he was negative for abdominal pain, constipation, and diarrhea. In a September 2016 statement, the Veteran’s primary care physician, M.D.S., M.D., noted that the Veteran had long-standing complaints of lower GI tract bowel urgency. The Veteran had told the doctor that it had been diagnosed at VA as IBS. He also presented a history of being hospitalized in 1957 where he was treated for fever, nausea, constipation, abdominal tenderness, and splenomegaly. His discharge diagnoses were fever of unknown etiology and common cold. He reported that he still suffered from recurrences of the same GI symptoms. The private physician related that the Veteran gave a history of being treated post service for his complaints, but that those records were unavailable. It was this examiner’s opinion that this was at least as likely as not that the Veteran’s current chronic bowel urgency disorder had its onset with the fever of unknown origin for which he was hospitalized in 1957. He had noted that many patients had had chronic bowel issues which had started after an acute event such as this. When examined by VA in December 2016, it was noted that the Veteran reported chronic diarrhea. Since 1957, he had experienced GI problems, to include fecal urgency. His stools were yellowish/brown in color and were explosive. Urgency episodes were frequent and occurred every day to every third day. It was the examiner’s opinion that the Veteran’s diarrhea was less likely than not (less than 50 percent probability) incurred in or caused by service. For rationale, it was noted that there did not appear to be a specific diagnosed chronic bowel issue or fecal urgency syndrome on active duty. It was further noted he was noted to be negative for diarrhea in 2011 and 2015. His active duty record indicated that he was thought to have been treated in 1957 for infectious mononucleosis, and while this diagnosis was not conclusively proven, the symptoms noted appeared most consistent with a diagnosis of mononucleosis which appeared to have been treated and resolved. In an October 2017 statement, the Veteran related that when he was flown home from service in 1957, he was still sick and knew that he had not completely recovered. At the April 2019 video conference hearing, the Veteran testified that he had had GI symptoms, to include chronic diarrhea ever since he was hospitalized in service in 1957. He said he had also been diagnosed with IBS. As requested by the Board in an October 2020 remand decision, additional VA examination was conducted in January 2020. The claim file was reviewed. The VA examiner opined that the condition claimed was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. For rationale, the examiner noted that he reviewed the claim file. The Veteran self-reported chronic diarrhea, to include upon VA examinations in 2012, 2016, and 2020. However, post service private records dated from 2011 through 2016 showed no corresponding GI complaints. He further noted that the Veteran denied diarrhea in 2011 and 2015. While it was noted that the Veteran’s primary care physician stated in September 2016 that the Veteran had a long history of GI tract bowel urgency, and opined that the disorder had its onset with the fever in 1957, the VA examiner could find evidence of such as there was no such corresponding complaints documented. Furthermore, there were no medical records from 1957 to 2011 (the earliest post service treatment medical records available) to support the report of ongoing diarrhea. The VA examiner did note that the Veteran was seen in 1956 for one episodes of gastroenteritis but that the conditions resolved without residuals. The VA examiner further noted that review of the in-service 1957 records reflect that it was felt that the Veteran had infectious mononucleosis. This disorder was an acute and self-limiting infection that did not cause long-standing chronic symptoms or any chronic pathology based on our medical understanding of that disease. Thus, it would not be expected to cause residual diarrhea symptoms or fecal urgency symptoms as the Veteran was now self-reporting many years later. The VA examiner further noted that symptoms of mononucleosis were discussed in the VA examination in 2016, but that diarrhea was not one of the classic symptoms, and the examiner at that time noted that the disorder was treated and resolved. In conclusion, based on all the evidence available, the examiner opined that there was no evidence to confirm a current pathology such as “chronic diarrhea” as self-reported by the Veteran. There were no treatment records which corroborated this disorder or further substantiation of a functional impairment or pathology or disability, despite the private physician’s September 2016 favorable opinion. Additionally, there was no evidence of any long-standing or chronic sequelae stemming from the 1957 hospitalization since there was no evidence demonstrating continuity of any chronic symptomatology from that event. It was further noted that an upper GI tract study and barium enema study in 1957 were negative. Thus, a pathology was not objectively demonstrated after separation from active duty service. For all these reasons, the VA examiner found no evidence to support a current diagnosis, including chronic diarrhea. Also, since a current diagnosis or disability was not objectively substantiated or confirmed, the disorder was less likely than not incurred in or caused by service. The Board finds the criteria for service connection for a chronic GI disorder, to include chronic diarrhea and/or IBS with bowel urgency, have not been met as the evidence does not show any such chronic symptom or disorder of service incurrence. In this case, the Veteran has a long history of GI complaints, to include chronic diarrhea and IBS with bowel urgency. The objective evidence of record, however, does not reflect that this history began until approximately 2012 when such symptoms were reported. While the Veteran has contended that his GI complaints began during his 1957 hospitalization, no such complaints were recorded, and no chronic disorder was diagnosed. Moreover, upon post service November 1957 upper GI tract and barium studies, both were found to be within normal limits. It was not until many years later that the Veteran filed for service connection for his GI symptoms in 2012 and reported such symptoms. The Board acknowledges the Veteran’s reports that he was treated in the post service years for his GI complaints, but that those records are unavailable, but there simply is no objective clinical evidence of continuity of GI symptoms from 1957 until 2012. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (a prolonged period without medical complaint can be considered, along with other factors concerning a claimant’s health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability). Thus, the lack of any evidence of GI symptoms or complaints or findings for over five decades between the Veteran’s military service and the earliest evidence of GI symptoms, is itself evidence which tends to show that any current GI symptoms did not have their onset in service or for many years thereafter. As noted above, there is a September 2016 private examiner’s opinion which is supportive of the Veteran’s contention that his GI complaints and/or diagnoses began while being treated during service in 1957. For rationale, the doctor said that he had many patients with chronic bowel issues which had started after an acute event such as this. This is in contrast to the January 2020 VA examiner’s opinion which found no actual presence of a confirmed chronic GI disorder. Upon a review of the conflicting medical opinions, the Board accords greater probative weight to the January 2020 VA examiner’s opinion in that he reviewed the entire claim file, to include all other opinions of record, and all in-service and post service treatment records. It was his opinion that while the Veteran self-reported chronic diarrhea and GI complaints, medical documentation confirming such was not of record. Moreover, GI tests in 1957, to include upper GI tract and barium enema, were negative, and it was many more years later before the Veteran actually reported GI complaints. He also explained how the Veteran’s likely treatment in 1957 for infectious mononucleosis was unrelated to any current GI complaints as that disorder did not cause GI symptoms. The VA examiner’s opinion was provided after a thorough review of the record, including the Veteran’s contentions, reflects consideration of all the relevant facts and relevant medical literature, and contains a detailed rationale for the findings reached. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion a medical opinion that contains only data and conclusions is not entitled to any weight); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion…must support its conclusion with an analysis that the Board can consider and weight against contrary opinion”). Therefore, while the private examiner’s September 2016 opinion does address the medical nexus question, it is afforded little, if any, probative weight, as if fails to provide a reasoned medical explanation for its conclusion. Nor did it include actual review of the entire claim file. The Board recognizes that the Veteran is competent to report symptoms which are readily apparent to a layperson (such as diarrhea and bowel urgency), but the record does not indicate that he has the education or training necessary to render a competent etiological opinion concerning his complaints. See Jandreau, supra. Regarding continuity of symptomatology, the Board acknowledges the Veteran is competent to report gastrointestinal problems. However, the Board places great probative weight on the records contemporaneous to seeking treatment such as the 2011 and 2015 treatment records which show the Veteran denied any diarrhea. TO the extent that the Veteran has stated he was diagnosed with IBS, the competent medical evidence of record does not show a diagnosis of the same. In this case for the reasons noted above, the Board finds that the preponderance of the evidence is against a finding that the Veteran has a chronic GI disorder that is due to his military service, or is otherwise related to his military service. Therefore, service connection for a chronic GI disorder, to include chronic diarrhea and/or IBS with bowel urgency, is denied. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Hal Smith, 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.