Citation Nr: 21022383 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 10-05 350 DATE: April 15, 2021 ORDER Entitlement to service connection for a gastrointestinal disorder, including due to exposure to environmental hazards from service in the Persian Gulf is denied. FINDING OF FACT The evidence fails to establish the Veteran’s current gastrointestinal (GI) disorder, diagnosed as lactose intolerance, was incurred in, or is otherwise etiologically related to, the Veteran’s active duty service or to his service-connected posttraumatic stress disorder (PTSD). CONCLUSION OF LAW The criteria for service connection for a GI disorder, including due to exposure to environmental hazards resulting from service in the Persian Gulf, have not been met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. §§ 3.2, 3.102, 3.303, 3.310, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1990 to June 1991, and from July 1993 to August 1993. The Veteran also had active duty for training from July 1990 to November 1990, as well as additional inactive service. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a May 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. This matter was previously before the Board in September 2017 and most recently in January 2021 when it was remanded for further development to include obtaining a VA medical opinion regarding the nature and etiology of the Veteran’s current gastrointestinal disorder. The examiner was asked to address conflicting medical evidence indicating diagnoses of both lactose intolerance and irritable bowel syndrome (IBS) and provide opinions for direct, secondary, and aggravation theories of service connection. The record shows VA obtained a January 2021 VA medical opinion. The Board notes that, to the full extent possible, VA complied with the remand instruction requests, and there exist no deficiencies in VA’s duties to notify and assist in that regard. See Stegall v. West, 11 Vet. App. 268 (1998). The matter has returned to the Board for further appellate review. The Veteran contends his GI disorder to include lactose intolerance and IBS, which is manifested by diarrhea, was caused by, or incurred during his active service in the Persian Gulf, or by his service-connected PTSD. See July 2012 Notice of Disagreement (NOD). Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. §§ 1110, 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). In addition, where a veteran served 90 days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such 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; 38 C.F.R. §§ 3.307, 3.309(a). Aside from the general statutes and regulations, service connection may also be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War. For disability due to undiagnosed illness and medically unexplained chronic multi-symptom illness (MUCMI), the disability must have been manifest either during active military service in the Southwest Asia Theater of operations or to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317. Under 38 C.F.R. § 3.317, a qualifying chronic disability is a chronic disability that results from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) the following MUCMIs that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) irritable bowel syndrome; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a MUMCI; or (C) any diagnosed illness that the Secretary determines, in regulations prescribed under 38 U.S.C. § 1117(d), warrants presumption of service connection. 38 C.F.R. § 3.317(a)(2)(i). “MUMCI” means a diagnosed illness without conclusive pathophysiology or etiology, characterized by overlapping symptoms and signs and that has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). The Veteran’s service treatment records (STRs) include December 1989 and April 1991 Reports of Medical Examination (RMEs); both are silent for GI issues. STRs also include December 1989, December 1990, and April 1991, Reports of Medical History (RMHs), wherein the Veteran denied stomach and intestinal trouble. STRs are otherwise silent for complaints of or treatment for gastrointestinal issues. Post-service treatment records include an August 2005 VA primary care record that noted the Veteran complained about diffuse abdominal pain and diarrhea within an hour after consuming dairy products. The Veteran denied heartburn, nausea, or vomiting. The record noted the Veteran used Lactaid milk instead of regular milk to decrease gastric symptoms. The record also noted the Veteran was diagnosed with lactose intolerance and advised to use Lactaid supplements prior to eating meals containing milk. A January 2009 primary care record noted the provider discussed lactose intolerance versus IBS. The record also notes the Veteran’s report of diarrhea after drinking milk and eating ice cream but not cheese. He has tried to avoid dairy products and when using lactose free products, he does not get diarrhea. The treatment record also noted the Veteran reported diarrhea when he gets stressed and at other times. He tried Lactaid but got no relief. Beer and tomato-based foods were also reported to cause diarrhea. The assessment/treatment plan noted a mixed picture of lactose intolerance and IBS; further testing should be considered. A January 2010 primary care record noted the Veteran continues to have occasional watery, non-bloody diarrhea, sometimes associated with mood, but other times associated with dairy products. The record noted a diagnosis of diarrhea / lactose intolerance / IBS. The primacy care provider encouraged the Veteran to avoid dairy products and recommended Imodium. An October 2013 GI clinic record noted the Veteran was referred for evaluation for chronic watery diarrhea. The Veteran reported certain foods make him have watery diarrhea instantly, particularly milk and milk products. On days with diarrhea, approximately 10 per month, the Veteran has 6-7 bowel movements. He takes Imodium with moderate improvement in symptoms. The assessment noted it was most likely that his symptoms were consistent with diarrhea predominant IBS. The provider indicated that a complete workup is necessary and ordered testing. An October 2013 GI clinic addendum noted a suspected diagnosis of IBS - diarrhea predominant. A subsequent January 2014 upper GI endoscopy report noted normal esophagus, normal stomach, and a normal duodenum. A June 2014 psychiatry medication management record noted the Veteran complained about gurgling and diarrhea after starting medication for anxiety and the Veteran does not like taking it. An October 2014 primary care record noted the Veteran’s IBS diarrhea was controlled by medication. A June 2015 primary care record noted that the Veteran continues to have diarrhea with IBS symptoms. Triggers include spicy foods, tomato-based products, and dairy. A diagnosis of IBS was noted with the use of prescription medication to control symptoms. A February 2016 primacy care record noted both diarrhea and lactose intolerance in active health problems. The Board also reviewed a March 2011 VA review PTSD examination wherein the Veteran reported that he is lactose intolerant and is taking lactose pills regularly. The examiner noted that the Veteran’s primary care physician had not yet determined a cause for the stomach issues. The Veteran was afforded a March 2012 Gulf War General Medical examination. The examiner noted that even though the claims file includes extensive medical records, there are no records of GI complaints prior to 2005, approximately 14 years after separation from active service. The Veteran has been diagnosed with lactose intolerance, and his history and symptoms are consistent with that diagnosis. The examiner noted there was insufficient evidence to support an IBS diagnosis. The examiner explained, even though IBS was mentioned in treatment records as a possible differential diagnosis starting in 2010, the Veteran’s symptoms are more consistent with the diagnosis of lactose intolerance. The examiner noted that IBS is primarily a diagnosis of exclusion, and the Veteran has never been thoroughly worked up for any other GI diagnoses, such as celiac disease, infectious bowel diseases, or inflammatory bowel diseases. The examiner concluded noting since the Veteran already has an appropriate diagnosis for his symptoms (lactose intolerance), an additional workup is not warranted. In an attached March 2012 VA stomach and duodenal conditions examination, the examiner confirmed a diagnosis of lactose intolerance. Noted symptoms included monthly abdominal pain, transient nausea, and mild vomiting. The examiner did not provide an etiology opinion. In the January 2021 VA medical opinion, the examiner was asked to opine if the Veteran’s current GI symptoms constituted either an undiagnosed illness, or a MUCMI to include a functional gastrointestinal disorder like IBS. The examiner opined that the Veteran’s GI disorder, including longterm diarrhea, is not an undiagnosed illness, nor is it a diagnosable but MUMCI of unknown etiology. The examiner noted that the Veteran’s condition is instead a clear diagnosis with specific etiology, specifically, lactose intolerance. The examiner noted the Veteran’s STRs were silent for GI problems. There is no evidence of chronicity to support a contention that the condition existed during the Veteran’s active service or within any presumptive period as diarrhea was first mentioned in August 2005 VA treatment records. The examiner was also asked to address conflicting medical evidence noting diagnoses of lactose intolerance and IBS. The examiner noted that IBS is a diagnosis of exclusion, and the symptoms described by the Veteran in the medical records are consistent with malabsorption such as would occur with lactose intolerance. The October 2013 initial GI consult opinion was based on a medical history provided by the Veteran that is controverted by the medical evidence of record. Therefore, the diagnosis of IBS cannot be supported. The same examiner opined that the Veteran’s current GI condition is less likely than not caused by proximately due to, secondary to, or aggravated by his service-connected PTSD, or medications used in the treatment of his PTSD. 38 C.F.R. § 3.310. As a rationale, the examiner stated that the medications noted to cause ‘stomach upset’ were discontinued, but the medical evidence indicates the Veteran continued to complain about GI problems. The examiner noted that if the medication was the cause, the GI complaints would have stopped with cessation of the medication. The Veteran’s January 2010 description that diarrhea “is sometimes associated with mood, but other times associated with dairy products” is the equivalent of causation. This statement reflects merely an association, probably confounded by recall bias, and at most could be considered an exacerbation but not and aggravation. The Veteran’s own statements, indicating that his diarrhea was a symptom of IBS and related to service in the Persian Gulf theater of operations do not constitute competent evidence. The question of whether the Veteran’s diarrhea is caused by lactose intolerance, IBS, or medications used to treat his service-connected PTSD is medical in nature, and beyond the scope of lay observation; it requires medical training and credentials. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Veteran is a layperson, and does not cite to supporting clinical data, a supporting medical opinion, or any supporting medical literature. Thus, his opinion regarding a nexus between GI problems manifested by diarrhea and Persian Gulf service is not competent evidence and has no probative value. The Board finds that the January 2021 VA medical opinion constitutes the most probative evidence of record. The examiner reviewed the claims file, including detailed treatment records, and provided a detailed rationale. The examiner found that the diagnosis was lactose intolerance, not IBS, and thus would be a known clinical diagnosis not subject to 38 C.F.R. § 3.317. In addition, the January 2021 medical opinion addressed direct and secondary service connection theories, including the question of aggravation, finding no basis for service connection. Put simply, under all posed theories, this opinion weighs strongly against the grant of service connection. In short, the preponderance of the evidence is against the Veteran’s claim, and the claim must be denied. In reaching the above conclusion, the Board has considered applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Banks, 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.