Citation Nr: 21015850 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 16-49 233 DATE: March 18, 2021 REMANDED Entitlement to service connection for ulcerative colitis is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from January 1976 to January 1977, and in the United States Army from February 2001 to October 2001, December 2002 to December 2003, December 2005 to February 2007, and February 2008 to April 2009 with periods of active duty for training and (ACDUTRA) and inactive duty training (INACDUTA) in June 2014. The Veteran had service in the Southwest Asia Theater. This matter comes before the Board of Veterans’ Appeals (Board) from rating decisions by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The Veteran testified before the undersigned in a May 2019 Board hearing; the transcript of that hearing is of record. In January 2020, the Board remanded this matter for further development. 1. Service connection for ulcerative colitis is remanded. The Veteran contends that his ulcerative colitis is due to his service in the Southwest Asia theater, notably exposures to burn pits. In January 2020, the Board remanded this matter to obtain a Gulf War Syndrome medical opinion and an opinion to determine whether the Veteran’s ulcerative colitis was due to the Veteran’s exposure to burn pits. In October 2017, the VA obtained an opinion regarding the Veteran’s ulcerative colitis. The examiner opined the Veteran’s ulcerative colitis was less likely than not incurred in or caused by the Veteran’s in-service injury, event, or illness. The examiner reasoned that the Veteran had multiple periods of activation. During one of those periods, in March 2008, the Veteran was seen for an acute gastroenteritis. The Veteran had one day of nausea and emesis. The examiner noted that this was an acute condition that was due to a virus and resolved. The examiner noted that the Veteran had annual health questionnaire in his reserve component in 2009, 2010, 2012, and 2013 and had denied any health conditions. The examiner further noted that the Veteran denied any gastrointestinal concerns in December 2013 and January 2015. The examiner stated that at the Veteran’s separation examination in February 2009 was negative for any gastrointestinal complaints or conditions. The Veteran PDHA and PDHRA in January and May 2009 were negative for gastrointestinal conditions. The Veteran’s PHA was negative for any gastrointestinal conditions. The examiner explained that the Veteran was not in duty status in March 2007 when he reported 5 days of blood after bowl movements. The examiner stated his condition resolved while not on duty status. The examiner noted that in October 2015 when the Veteran was diagnosed with ulcerative proctitis he was not on active duty. The examiner concluded there was no nexus to service. In March 2020, the Veteran underwent a VA examination. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury event or illness. The examiner reasoned that the Veteran had rectal bleeding in 2007 after a few weeks from returning from active duty. A biopsy showed some non-specific inflammation and ulcerative colitis was not seen by the pathologist. The Veteran was diagnosed with ulcerative colitis in 2015, six years after separation from service on the basis of biopsy. The examiner stated that there is no evidence of bleeding, constipation, diarrhea, or other gastrointestinal problems between the 2007 episode and the one in that resulted in the 2015 diagnosis. The examiner noted that over the years the Veteran’s service treatment records after 2007 indicate that he had knee trouble and back trouble, but not other problems. The examiner stated that there is not a nexus to service. The examiner explained that the lack of ongoing symptoms after the initial biopsy (which did not show ulcerative colitis) until the Veteran had bleeding that resulted in the 2015 biopsy is not consistent with the natural history of ulcerative colitis. The examiner noted that the onset of symptoms is usually gradual, and symptoms are progressive over several weeks. Symptoms may be proceeded by a self-limited episode of rectal bleeding that occurred weeks or months earlier. The examiner explained that the symptoms that occur prior to a diagnosis start weeks or months, rather than years before the diagnosis. The examiner explained that the Veteran’s 2007 rectal bleeding appeared to have been a separate acute and transitory finding, rather than the start of ulcerative colitis within a few weeks of separation. The examiner noted that the Veteran’s initial bleeding episode only lasted a few days, resolved without treatment and he did not have intermittent exacerbations. The examiner noted that the Veteran suspected his Gulf War exposure to burn pits led to his ulcerative colitis. The examiner stated that at this time Uptodate.com and a search on Google Scholar do not support this contention. The examiner disregarded the private opinion that the Veteran’s intestines were affected by exposure to burn pits and sandstorms because it was not probative due to the lack of a rationale. In September 2020, the Veteran underwent a Gulf War examination. The examiner found the Veteran’s ulcerative colitis was a disease with a clear and specific etiology and diagnosis. The examiner explained that ulcerative colitis is an inflammatory bowel disease that causes long-last inflammation and ulcers (sores) in the digestive tract. This is caused when the immune system tries to fight off an invading virus or bacterium, an abdominal immune response causes the immune system to attack the cells in the digestive tract. Therefore, the condition is unrelated to a specific exposure event experienced during service in Southwest Asia. In October 2017, the Veteran stated that he had symptoms of ulcerative colitis during service. The Veteran stated he first had bleeding in his stool in 2008 and lasted on and off until 2014, upon it got worse. The Veteran stated he was diagnosed with ulcerative colitis in 2015. The Veteran testified in a May 2019 Board hearing. The Veteran stated that he had bleeding during bowl movements in about 2007 and 2008. The Veteran stated he noticed his symptoms shortly after leaving service in 2007. The Veteran stated that between February 2007 and February 2008 he received treatment for the bleeding but did not have a formal diagnosis. The Veteran stated he did not receive a formal diagnosis of ulcerative colitis until 2016. The Veteran stated while he was deployed in February 2008 to April 2009 the Veteran did not see anyone for his bleeding. The Veteran stated when he separated from service in 2009, he did not have any bleeding. The Veteran noted that the bleeding caused him fatigue. The Veteran stated that his bleeding started again in 2015. The Veteran stated his provider believed the bleeding in 2008 and 2007 was indicative to what turned out to be his ulcerative colitis. The Veteran stated he discussed with his provider that the burning pits directly caused the infection of the intestines that led to the colitis. The Veteran stated that in 2007 he had a negative colonoscopy and the bleeding stopped. The Veteran noted that he did not notice bleeding while he was deployed. The Board finds that a remand is required. The March 2020 examiner’s rationale determined that the Veteran’s blood in his stool was not indicative of the onset for the Veteran’s ulcerative colitis because the blood was in the Veteran’s stool for only in a few days. The Board finds that to be a mischaracterization of the facts in the evidence. VA treatment records indicate that the Veteran had blood in his stool for the previous 5 days on March 8, 2007. Treatment records further note that on March 28, 2007 the Veteran reported blood in his stool. The Veteran underwent a colonoscopy in May 2007 that indicated indeterminate colitis. At this point, there is no indication the blood in the Veteran’s stool had ceased. The Veteran reported during his May 2019 testimony that he had blood in his stool in-between his deployments from February 2007 to February 2008. Although it appears that the blood in his stool did resolve sometime prior to his February 2008 deployment, characterization blood in stool for a month (if not longer) as a “few days” cannot be an adequate basis for a negative opinion. The Board finds the March 2020’s examiner’s reasoning that exposure to burn pits was not the cause of Veteran’s ulcerative colitis due to a search of Google Scholar and Uptodate.com is not a sufficient rationale. Such a rationale is unclear as to whether there is no literature regarding ulcerative colitis and exposure to burn pits or whether there is literature that directly addresses this issue. The Board notes the lack of medical literature on an issue is not a reasonable rationale for a negative opinion. The Board also takes note that March 2020 examiner did not address the July 2018 medical opinion because it did not include a rationale thus deeming it not probative and not giving it much weight in the opinion. The Board finds it unclear why a medical opinion (albeit without a rationale) is less probative than a negative internet search. Finally, the September 2020 Gulf War VA examiner described how ulcerative colitis is caused. The September 2020 examiner explained that it is caused when the immune system tries to fight off an invading virus or bacterium, an abdominal immune response causes the immune system to attack the cells in the digestive tract. The Board finds that there is no opinion which addresses whether exposure to a burn pits or sandstorms caused the Veteran’s immune system response. Therefore, the Board finds that a remand is required for an addendum medical opinion, to determine whether the Veteran’s service, including exposure to burn pits and/or sandstorms caused the Veteran’s ulcerative colitis. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from an appropriate clinician to determine the etiology of the Veteran’s ulcerative colitis. The examiner must opine as to the following: (a.) Whether the Veteran’s ulcerative colitis is at least as likely as not related to service, including exposure to burn pits and/or sandstorms. i. The examiner must address the May 2007 colonoscopy report that indicated indeterminate colitis. ii. The examiner must address the September 2020 Gulf War examiner’s opinion that ulcerative colitis is caused by a bacteria or virus which instigates an immune response and whether exposure to burn pits would cause this immune response. iii. The examiner must address the July 2018 medical opinion that exposure to burn pits and sandstorms caused permanent damage to the Veteran’s intestines. (b.) The examiner must provide a complete medical rationale for all opinions provided. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Robert Batten 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.