Citation Nr: 21021837 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 13-06 826 DATE: April 14, 2021 ORDER Entitlement to service connection for an upper gastrointestinal (GI) disability is denied. Entitlement to service connection for a lower GI disability is denied. REMANDED Entitlement to service connection for a back disability is remanded. FINDINGS OF FACT 1. An upper GI disability was not present during the Veteran’s active service and is not otherwise etiologically related to such service, and the Veteran has not been shown to have had a peptic ulcer that was present to a compensable degree within a year of her separation from service. 2. A lower GI disability was not present during the Veteran’s active service and is not otherwise etiologically related to such service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for an upper GI disability have not been met. 38 U.S.C. §§ 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 2. The criteria for entitlement to service connection for a lower GI disability have not been met. 38 U.S.C. §§ 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active air service from April 1973 to August 1980. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In August 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the claims file. This case was previously before the Board in February 2019, at which time the issues currently before the Board were remanded for additional development. The case has now been returned to the Board for further appellate action. The issues of entitlement to service connection for right and left knee disabilities were also remanded by the Board in February 2019. However, in a December 2020 rating decision, the Veteran was granted entitlement to service connection for her right and left knee disabilities. There is no indication from the record that the Veteran has disagreed with the ratings or effective dates assigned in that decision. Therefore, that decision constitutes a full grant of the benefit sought on appeal and the Board has limited its consideration accordingly. Service Connection — Upper and Lower GI Disabilities The Veteran asserts that she has upper and lower GI disability that are related to her active service. Service treatment records (STRs) show that the Veteran was seen in December 1973 for complaints of dark stools and nonspecific abdominal pain. She denied vomiting and diarrhea at that time. The Veteran was diagnosed with viral gastroenteritis. An upper GI series was completed, and there were no significant abnormalities noted. There is no indication from the STRs that the Veteran’s symptoms did not resolve. In February 1978, the Veteran was seen for complaints of diarrhea, body aches, and headache. The Veteran was diagnosed with viral syndrome at that time, and treated with bed rest, fluids, and Tylenol. There is no indication from the record that the Veteran’s symptoms did not resolve without residual. In May 1978, the Veteran was seen for complaints of nausea, but reported that she felt well otherwise. There was no diagnosis of a chronic disability made at that time, and the Veteran was treated and told to return to the clinic if symptoms did not improve. There is no indication from the record that the Veteran’s symptoms failed to abate, or that she sought follow-up at that time. In December 1978, the Veteran was seen for complaints of nausea, vomiting, and profuse diarrhea. At that time, the Veteran was diagnosed with acute gastroenteritis. There is no indication from the STRs that the gastroenteritis did not completely resolve without residual. In February 1980, the Veteran was seen for complaints of nausea with abdominal cramping. At that time, the Veteran denied a history of bowel disease. The Veteran was diagnosed with gastroenteritis, placed on clear liquids and bed rest for treatment, and told to return to the clinic if she was no better in 24 hours. There is no indication from the STRs that the Veteran’s symptoms did not completely resolve without residual as she was not seen for follow-up at that time. In May 1980, the Veteran was afforded a separation examination. At that time, she did mark “yes” on the report of medical history to the question of whether she experienced frequent indigestion, but she denied stomach or intestinal problems at that time. Her abdomen and viscera were noted to be clinically normal on physical examination at that time, and there is no indication from the separation examination report that the Veteran was found to have an upper of lower GI disability at the time of her separation from active service. A review of the post-service medical evidence of record shows that the Veteran was diagnosed with a variety of upper and lower GI disabilities over the years, to include irritable bowel syndrome, gastritis, peptic ulcers, a hiatal hernia, diverticulosis, gastroesophageal reflux disease (GERD), and reflux esophagitis. However, there is no indication from the post-service treatment notes of records that the Veteran’s various diagnoses have been linked to her active service. Further, the Veteran underwent an esophagogastroduodenoscopy (EGD) in August 2010, which revealed that her gastritis and peptic ulcer had resolved. At a March 2011 VA examination, the Veteran reported that her abdominal symptoms began as gastroenteritis, which then became diverticulitis. The Veteran reported that her current diverticulitis was a continuation of the gastroenteritis she had during active service. She also reported having an ulcer and a hernia, which were also reportedly stemming from her in-service gastroenteritis. She reported having EGDs in August 2010 and October 2010. She reported that she was diagnosed with irritable bowel syndrome in 1994, but the examiner noted that those records were unavailable. The examiner diagnosed irritable bowel syndrome by history, and noted that she had a normal colon scope and there was no clinical evidence of diverticulitis, and gastritis by history, with no clinical evidence of ulcer. The examiner opined that it was less likely as not that any of the Veteran’s diagnosed GI disabilities were caused by, or the result of her active service. In so finding, the VA examiner noted that the Veteran was diagnosed with acute gastroenteritis while in active service, in addition to being seen on several occasions for nausea and abdominal pain. However, an upper GI series performed during service did not reveal any significant abnormalities. The examiner noted that gastritis was inflammation of the stomach lining and had many possible causes, the Veteran’s in-service diagnosis of gastroenteritis was acute and transitory, and there was no evidence of a chronic GI disease, to include irritable bowel syndrome or ulcer, during the Veteran’s active service. In January 2020, the Veteran was afforded a VA stomach and duodenal conditions examination. At that time, the Veteran reported that she first experienced indigestion in 1974, while in active service, and that it had persisted ever since. She reported that in 2010, she was found to have gastritis and peptic ulcers, which subsequently resolved. She also reported that she had been diagnosed with GERD. Based on a review of the record and examination of the Veteran, the examiner found that the Veteran did not have a diagnosis of a disability pertaining to the stomach or duodenum. The Veteran was also afforded a VA intestinal conditions examination in January 2020. At that time, the Veteran reported that she had experienced persistent diarrhea during active service, and that it had persisted ever since. The Board acknowledges that the VA examiner did not a diagnosis of irritable bowel syndrome in 1974. However, that is not otherwise evidence by the record, and there is no objective medical evidence to support that finding, or a finding of a current diagnosis of irritable bowel syndrome. The January 2020 VA examiner opined that the Veteran did not have a GI disability that was as likely as not incurred in or caused by the claimed in-service injury, event, or illness. In so finding, the examiner noted that there was insufficient, objective evidence in the claims file of a chronic stomach or duodenal condition. The examiner noted that all documentation in the record was consistent with past, acute viral infections that resolved. Further, the examiner noted that the 2010 diagnosis of gastritis/ulcers in 2010 (which was proven to resolve on subsequent EGD) was not due to active service as a result. The Board finds that the March 2011 and January 2020 VA medical opinions are adequate when read in conjunction with one another. In this regard, the examiners thoroughly reviewed and discussed the relevant evidence, considered the contentions of the Veteran, and provided a supporting rationale for the conclusions reached. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Further, there is no medical opinion of record to the contrary. As such, the VA medical opinions are the most probative evidence of record. While the Veteran is competent to report observable symptoms, she is not competent to provide an opinion linking a current upper or lower GI disability to her active service. An opinion of that nature requires medical expertise and is outside the realm of common knowledge of a layperson. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Veteran is not competent to provide an etiology opinion in this case. Further, the Veteran has not been found to have an ulcer that was manifest to a compensable degree within a year of her separation from active service. Therefore, presumptive service connection is not applicable in this case. 38 C.F.R. § 3.309 (2020). Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to service connection for an upper GI disability and a lower GI disability is not warranted. 38 U.S.C. § 5107 (b) (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Service Connection – Back Disability The Board finds that additional development is required before the claim on appeal is decided.   In this regard, for her claimed back disability, the Veteran was afforded a VA examination in November 2020. The examiner opined that the Veteran’s back disability was less likely as not proximately due to or the result of the Veteran’s service-connected knee disabilities. In so finding, the examiner failed to address whether the Veteran’s back disability was aggravated by his service-connected knee disabilities. Therefore, the Board finds that the development conducted does not adequately comply with the February 2019 Board remand directives. Compliance with a remand is not discretionary, and failure to comply with the terms of a remand necessitates remand for corrective action. Stegall v. West, 11 Vet. App. 268 (1998). Therefore, an addendum medical opinion must be obtained before a decision is made in this appeal. The matters are REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file. 2. Then, forward the claims file to the VA examiner who provided the November 2020 medical opinion for an addendum opinion. The examiner must review the claims file, and note that review in the report. Based on a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present back disability was caused or aggravated by a service-connected disability, to specifically include the Veteran’s service-connected knee disabilities. The rationale for all opinions expressed must be provided. If the examiner who conducted the November 2020 VA examination is not available, the claims file should be forwarded to another VA examiner with the appropriate expertise to provide the requested medical opinions. A new examination of the Veteran should only be performed if deemed necessary by the examiner provided the requested medical opinions. 3. Confirm that all medical opinions provided comport with this remand and undertake any other development determined to be warranted. (Continued on the next page)   4. Then, readjudicate the remaining issue on appeal. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board I. Umez-Eronini, 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.