Citation Nr: 21025660 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 18-50 378 DATE: April 28, 2021 ORDER Entitlement to service connection for a gastrointestinal disorder, to include as due to herbicide agent exposure and/or secondary to service-connected post-traumatic stress disorder (PTSD), is denied. FINDING OF FACT The Veteran’s gastrointestinal disorder is not caused or aggravated by service-connected PTSD and is not otherwise related to an in-service injury or disease, to include herbicide agent exposure. CONCLUSION OF LAW The criteria for entitlement to service connection for a gastrointestinal disorder, to include as due to herbicide agent exposure and/or secondary to service-connected PTSD, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1968 to June 1970. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a November 2017 rating decision issued by the Department of Veterans’ Affairs (VA) Regional Office (RO). By way of background, the Board previously remanded this claim in August 2019 for additional development. As will be discussed in more detail below, the Board finds substantial compliance with the August 2019 remand directives has been met. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Entitlement to service connection for a gastrointestinal disorder, to include as due to herbicide agent exposure and/or secondary to service-connected PTSD, is denied. The Veteran contends his gastrointestinal disorder was caused by or incurred during service, to include as due to herbicide agent exposure, or in the alternative, is secondary to his service-connected PTSD. The Board finds service connection on a direct or secondary basis is not warranted. Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in the line of duty, or for the aggravation of a pre-existing injury or disease in the line of duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Veterans who, during active service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence of non-exposure. 38 U.S.C. § 1116; 38 C.F.R. § 3.307. Here, the Veteran’s herbicide agent exposure has already been conceded by the Board as part of the August 2019 decision based, in-part, on the Veteran’s DD-214 confirming service in the Republic of Vietnam from December 1969 to June 1970. If a Veteran was exposed to an herbicide agent (to include Agent Orange) during active military, naval or air service and has contracted an enumerated disease to a degree of 10 percent or more at any time after service, the Veteran is entitled to a presumption of service connection even though there is no record of such disease during service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309(e). In this case, however, the Veteran’s gastrointestinal disorder is not included in the list of disease for which the presumption applies. 38 C.F.R. § 3.309(e). In the event a Veteran has at least one service-connected disability, he or she may be entitled to benefits based on a secondary service connection. In order to establish a secondary service connection, the Veteran must show: (1) a current disability that is not already service-connected; (2) at least one service-connected disability; and, (3) evidence that the non-service-connected disability is either proximately due to or aggravated beyond its natural progression by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 444 (1995). Here, the Veteran is service connected for PTSD which he contends has caused or aggravated his gastrointestinal disorder. When service connection cannot be established on a secondary basis, the Court has held that the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. See Combee v. Brown, 34 F.3d 1039 (1994). The elements of direct service connection are: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service,” also known as the nexus element. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Turning to the relevant evidence of record, upon entrance, the Veteran declined stomach, liver, or intestinal trouble. See February 1968 entrance examination. He was clinically evaluated as normal. Id. During service, the Veteran’s treatment records lack any complaints of, treatment for, or diagnosis related to gastrointestinal disorders. At separation, the Veteran again declined experiencing stomach, liver, or intestinal trouble. See June 1970 separation examination. He was clinically evaluated as normal. Id. In 2003, the Veteran received emergency care with complaints of “stomach problems.” See March 2003 VA treatment records. In May, he reported a history of colitis with complaints of chronic diarrhea. See May 2003 VA treatment records. In June 2009, the Veteran reported diet related diarrhea. See June 2009 VA treatment records. In August 2010, the Veteran reported that he had a colonoscopy within the last 5 to 10 years. See August 2010 VA treatment records. The provider indicated the Veteran had a colonoscopy in March 2010 that was normal with two benign polyps and diverticulosis. Id. In August 2014, the Veteran reported chronic diarrhea that was stable and referenced extensive workup with a private gastrointestinal provider. See August 2014 VA treatment records. In August 2016, the Veteran attended a follow-up for a colonoscopy which was completed in July 2016. See August 2016 non-government treatment records. The colonoscopy results revealed pan colitis. Id. The Veteran reported experiencing diarrhea but declined bleeding or pain. Id. He was noted to have 2-6 unformed bowel movements per day. Id. A diagnosis of ulcerative (chronic) pancolitis without complications was noted. Id. In September 2016, the Veteran reported continued diarrhea with two loose bowel movements. He was assessed with Crohn’s disease, unspecified, without complications. See September 2016 non-government treatment records. Treatment records in 2016 and 2017 reflect continued treatment for ulcerative colitis and/or Crohn’s disease. See August 2016 and April 2017 VA treatment records. The Veteran was afforded a VA examination to determine the nature and etiology of the Veteran’s gastrointestinal disorders in February 2020. The Veteran was noted to have a diagnosis of Crohn’s disease in 2016. See February 2020 VA examination. The Veteran reported that he was diagnosed about three years ago. Id. He described problems with chronic diarrhea for “most of my life” with an onset “not long after returning from Vietnam.” Id. He stated that he has had several colonoscopies performed over the years and stool testing which yielded the Crohn’s diagnosis. Id. He denied family history of Crohn’s disease. Id. He believes that in the absence of risk factors for his Crohn’s, his herbicide agent exposure is the likely cause of his condition. Id. The examiner reported that the Veteran takes medication daily for treatment while indicating that the Veteran has exacerbations or attacks of the intestinal condition at a frequency of more or less constant abdominal distress. Id. In the past 12 months, the Veteran had zero episodes of exacerbations and/or attacks of the intestinal condition. Id. The examiner opined that it is less likely than not the Veteran’s Crohn’s disease had an onset during service or is otherwise related to service, including conceded herbicide agent exposure. Id. The examiner reasoned the Veteran’s STRs are negative for diagnosis and treatment for diarrhea, Crohn’s disease, or chronic GI conditions. Id. Following separation, the Veteran’s treatment records reflect a diagnosis of Crohn’s disease in 2016, over forty years after separation. Id. The examiner noted review of the Veteran’s submitted journal articles including one discussing gastrointestinal disorders in Veterans returning from Iraq and Afghanistan, another referencing a high incidence of chronic functional GI disorders in Veteran’s deployed during the Gulf War, and a fact sheet referencing potential environmental and autoimmune causes of Crohn’s. Id. The examiner explained, however, that according to UpToDate, the age of onset for many patients with Chron’s disease is between 15 and 30 with some studies suggesting a possible second peak between 50 and 80 years of age. Id. The examiner quoted the article stating, “It is not clear whether this second peak relates to greater susceptibility to disease with older age, the late expression of an earlier environmental exposure, or higher rates of health care utilization in older persons.” Id. The examiner further referenced the multiple risk factors reported in the article as associated with higher risk of Crohn’s disease, but found that specific environmental exposures including herbicide agent exposure, have not been causally linked to the development of Crohn’s disease. Id. The examiner reviewed additional medical articles and data acknowledging that while some suggest a possible increase in irritable bowel disease related to environmental factors, there is no conclusive evidence of causation. Id. Specifically, the examiner opined that evidence of an association between herbicide agent exposure and the development of Crohn’s disease is not supported by current medical literature. Id. The examiner also opined that it is less likely than not that the Veteran’s Crohn’s disease is proximately due to or aggravated by his service-connected PTSD. Id. The examiner explained the risk factors associated with Crohn’s disease include genetic factors, race/ethnicity, smoking history, physical activity, and dietary factors. Id. The examiner explained that UpToDate recognized studies examining an association between psychological factors and the risk of developing IBD have yielded inconsistent results. Id. The studies, however, have shown that stress may have a role in the exacerbation of the enteric nervous system and the production of proinflammatory cytokines. Id. The examiner noted that the Veteran’s Crohn’s disease is stable on monotherapy, requiring no hospitalizations, productive of no complications such as strictures, abscesses, fistulas, and without extraintestinal or neoplastic manifestations to suggest an abnormal progression of disease beyond its natural course. The Board finds the February 2020 VA examination includes consideration of the Veteran’s medical history and sets forth all pertinent findings, such that the Board is able to make a fully informed decision. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). When considered together with the entire evidence of record, the Board finds the examination adequate for adjudication of the Veteran’s service connection claim because it is based upon an accurate medical history and provides explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (once VA undertakes to provide a medical examination or opinion, it must ensure that the examination or opinion is adequate). It is undisputed based on the evidence of record that the Veteran has been diagnosed with Crohn’s disease in 2016. As mentioned previously, while the Veteran’s herbicide agent exposure during service has been conceded, Crohn’s disease is not a condition for which the presumptions relating to herbicide agent exposure applies. Regarding secondary service connection, the Veteran is currently service connected for PTSD. The preponderance of the evidence, however, is against finding that the Veteran’s Crohn’s disease is proximately due to or aggravated beyond its natural progression by his PTSD. The February 2020 VA examiner opined that the Veteran’s Crohn’s disease was not caused by his service-connected PTSD. The Board finds the examiner’s secondary causation opinion to be highly probative as it is based on a review of the Veteran’s treatment records and has a rationale is support thereof. Indeed, the examiner acknowledged medical evidence of an association between PTSD and Crohn’s disease, but found that causation has not been established. Thus, the Board finds the preponderance of the evidence is against finding the Veteran’s Crohn’s disease was caused by his PTSD. The Board also finds the February 2020 VA examiner’s opinion regarding aggravation to be highly probative. The examiner found that the Veteran’s Crohn’s disease has not been aggravated beyond its natural progression by his PTSD. The examiner acknowledged the medical articles noting that stress could exacerbate Crohn’s disease, but found the Veteran’s Crohn’s disease has been managed and there has not been an episode of exacerbation and/or attack of the intestinal condition in the last year. Further, the examiner’s opinion is corroborated by the Veteran’s medical records which lack complaints of or reference to Crohn’s symptoms occurring or worsening during periods of stress or PTSD episodes. The Board notes the Veteran submitted medical articles discussing a relationship between PTSD and Crohn’s disease. These articles, however, are not specific to the Veteran’s facts and medical history and, therefore, cannot support a nexus. See Sacks v. West, 11 Vet. App. 314, 317 (1998) (holding that generic medical treatise evidence cannot, without more, provide the medical nexus necessary to establish entitlement to benefits). Accordingly, the Board assigns these medical articles no probative value as to the medical questions at issue. Id.; see also 38 C.F.R. § 3.159; see e.g., Wallin v. West, 11 Vet. App. 509, 514 (1998). Further, the February 2020 VA examiner reviewed the medical articles of record in rendering his opinion which recognized that stress may exacerbate aspects of Crohn’s disease. Even in light of the articles submitted to the record, the examiner opined that the Veteran’s Crohn’s disease is less likely than not aggravated by his PTSD, which the Board finds most probative. Thus, the Board finds while medical articles note stress may exacerbate Crohn’s, in this case, the preponderance of the evidence is against finding the Veteran’s Crohn’s disease has been aggravated by his PTSD. Service connection may still be awarded on a direct basis. The question for the Board is whether the Veteran’s Crohn’s disease was caused by or incurred during service including as due to herbicide agent exposure. Upon review, a nexus to service has not been established. While the Veteran contends his gastrointestinal symptoms began during service or sometime in the 1970s following separation, the Board finds the STRs are silent regarding complaints, treatment, or diagnosis related to a gastrointestinal disorder. Additionally, the record lacks treatment records following separation noting complaints of gastrointestinal symptoms until 2003. Although a lack of contemporaneous medical evidence does not automatically constitute substantive negative evidence, the Board may weigh the absence of contemporaneous records when assessing the credibility of lay evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011). In this case, however, the Board finds the Veteran’s STRs, separation examination, and treatment records after service to be more probative than his lay statements of symptoms considering he was not diagnosed with Crohn’s disease until 2016, decades following separation, and his first documented complaints of digestive symptoms occurred in 2003, also decades after service. Further, the Veteran sought medical treatment during service and after separation during which he never complained of gastrointestinal symptoms. The Veteran contended that he has had numerous colonoscopies and has been treated outside of the VA. On remand, the VA requested the private treatment records referenced by the Veteran. Said records reflect a colonoscopy in 2016 leading to the diagnosis of Crohn’s disease in 2016. Thus, the Board assigns more probative value to the competent and credible medical evidence of record lacking complaints, treatment, or diagnosis of a gastrointestinal disorder until 2003 than the Veteran’s uncorroborated statements of symptoms made in association with a claim for benefits. The Veteran also contends his Crohn’s disease was caused by herbicide agent exposure. To this point, the Board finds the February 2020 VA examiner’s opinion to be highly probative. The examiner explained the many risk factors for Crohn’s disease, which did not include herbicide agent exposure. The examiner acknowledged that Crohn’s disease at an older age may be an expression of an earlier environmental exposure, but further explained that specific environmental exposures, including herbicide agent exposure, have not been causally linked to the development of Crohn’s disease. The examiner further noted that the medical literature lacks conclusive evidence of causation between herbicide agent exposure and Crohn’s disease. The Board again notes the Veteran submitted medical articles discussing a relationship between Crohn’s disease and herbicide agent exposure. These articles, however, are not specific to the Veteran’s facts and medical history and, therefore, cannot support a nexus. See Sacks, 11 Vet. App. at 317. Accordingly, the Board assigns these medical articles no probative value as to the medical questions at issue. Id. Further, the February 2020 VA examiner reviewed the medical articles of record in rendering his opinion as well as other medical literature which has not established a causative relationship between Crohn’s disease and herbicide agent exposure. Even in light of the articles submitted to the record, the examiner opined that the Veteran’s Crohn’s disease is less likely than not caused by herbicide agent exposure during service, which the Board finds most probative. While the Veteran believes his Crohn’s disease is caused by herbicide agent exposure, he is not competent to provide a nexus opinion in this case. This issue is medically complex, as it requires specialized medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Thus, the Board gives more probative weight to the competent medical evidence of record including the February 202 VA examiner’s opinions. Based on the aforementioned, the Board finds the preponderance of the evidence is against an award of service connection for Crohn’s disease. As such, the benefit-of-the-doubt doctrine is not for application and the claim must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). SHEREEN M. MARCUS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.C. Allen, 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.