Citation Nr: 21032885 Decision Date: 05/28/21 Archive Date: 05/28/21 DOCKET NO. 16-20 659 DATE: May 28, 2021 ORDER Entitlement to service connection for an esophagitis disability is denied. REMANDED Entitlement to service connection for an impairment of rectal sphincter control due to the Veteran's service-connected disability of Crohn's disease with irritable bowel symptoms, aphthous ulcers status post cholecystectomy with scars is remanded. Entitlement to service connection for an acquired psychiatric disorder to include anxiety disorder due to the Veteran's service-connected Crohn's disease with irritable bowel symptoms, aphthous ulcers status post cholecystectomy with scars is remanded. FINDING OF FACT 1. The preponderance of the evidence is against finding that an esophagitis disability began during active service or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW 1. The criteria for service connection for an esophagitis disability is not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 2003 to June 2009. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for an esophagitis disability The Veteran contends his esophagitis is due to active duty service. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 38 C.F.R. § 3.303(a). "To establish a right to compensation for a present disability, a Veteran must show: '(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' - the so-called 'nexus' requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Disorders diagnosed after discharge will still be service connected if all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Service treatment records are silent of complaints, diagnoses, and findings for esophagitis. Post service treatment records reveals on January 14, 2014, esophagitis in the gastroesophageal junction. In this case, service treatment records are silent of complaints, diagnoses, and findings of an esophagitis injury. Post service treatment records reveal on January 14, 2014 esophagitis in the gastroesophageal junction, but there is no medical evidence linking the current esophagitis disability to service. While the appellant may sincerely believe that his esophagitis disorder is related to service, as a lay person untrained in the field of medicine he is not competent to offer a medical opinion linking his current diagnoses to service. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board finds the VA is not obliged to provide an examination or obtain an opinion for the Veteran's claimed condition because there is no competent evidence indicating a link between the Veteran's esophagitis disability and service. The Veteran's "conclusory generalized statement that his service illness caused his present medical problems" is not enough to entitle him to an examination. Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010). Without a link to service, service connection cannot be granted. Since the preponderance of the evidence is against the claim, reasonable doubt may not be resolved in the Veteran's favor. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, the Veteran's claim of entitlement to service connection for an esophagitis disability is denied. REASONS FOR REMAND 1. Entitlement to service connection for an impairment of rectal sphincter control due to the Veteran's service-connected disability of Crohn's disease with irritable bowel symptoms, aphthous ulcers status post cholecystectomy with scars is remanded. The Veteran contends his impairment of rectal sphincter control is due to his service-connected disability of Crohn's disease with irritable bowel symptoms, aphthous ulcers status post cholecystectomy with scars. Service treatment records reveal complaints of incontinence caused by loose and watery stools, and the Veteran was diagnosed with a loose anal sphincter in September 2007. A VA examination was conducted on August 6, 2009. There was no evidence of fecal leakage, bleeding or fissures or impairment of rectal sphincter control. In June 2011, the Board received a letter from the Veteran. The Veteran stated he had an inability to control his bodily function which resulted in bowel incontinence. So, he enrolled in vocational rehabilitation to assist him because he feared having an accident in the workplace, and he had several accidents at a home. He also stated during an appointment, his Gastroenterologist told him his Crohn's was clearing but there is no telling whether or not his urgency will ever clear and there is no medication to treat the urgency. A VA examination was conducted in March 2013. The examiner diagnosed the Veteran with an impairment of the rectal sphincter control. The examiner opined the rectum condition is less likely than not proximately due to or the result of the Veteran's service-connected disability. The examiner stated Crohn's disease does not cause incontinence in the absence of perianal disease. However, the examiner failed to address whether the Veteran's rectal sphincter is aggravated by his service-connected Crohn's disease. Where secondary service connection is asserted, an examination must offer an opinion as to aggravation in addition to direct causation. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41(2013); Allen v. Brown, 7 Vet. App. 439, 448 (1995). A colonoscopy performed in February 2016 revealed a loose sphincter tone and crypt architectural changes which may represent quiescent disease. In February 2020, the Veteran submitted a brief from his attorney. In the brief, his attorney argued that the examination conducted on March 15, 2013 was inadequate for several reasons. The examiner opined that the Veteran's "loss of rectal sphincter control is less likely than not due to his service-connected Crohn's disease due to the absence of perianal disease, a specific category of Crohn's Disease. Nowhere in the C&P examination does the examiner address whether [the Veteran] has perianal disease or what type of Crohn's disease [he] does have." She also identified an internal inconsistency in the examination regarding whether the Veteran has incontinence attributable to impaired rectal sphincter control. Finally, the opinion appears to be written by a different individual than the person who performed the examination. Additionally, she stated pathological findings in a private biopsy in the claims file showed that there were mild crypt architectural changes in the Veteran's colon which are related to Crohn's disease and a cited medical article indicated anal crypts could be indicative of perianal disease. The article, "Perianal Crohn's Disease" is available at www.ncbi.nlm.nih.gov/pmc/2780223/. Thus, a remand is needed to address whether the Veteran's impairment of rectal sphincter control is aggravated by his Crohn's disease, whether rectal sphincter control impairment is itself a symptom of Crohn's disease, and the relevant medical literature cited in the brief. 2. Entitlement to service connection for an acquired psychiatric disorder to include anxiety disorder due to the Veteran's service-connected Crohn's disease with irritable bowel symptoms, aphthous ulcers status post cholecystectomy with scars is remanded. The Veteran contends his acquired psychiatric disorder to include an anxiety disorder is due to his service-connected Crohn's disease with irritable bowel symptoms, aphthous ulcers status post cholecystectomy with scar. A VA examination was conducted in March 2013. The examiner diagnosed the Veteran with an anxiety disorder that was unrelated to military service. The examiner opined, it is this examiner's opinion that it is NOT LIKELY that the Veteran's anxiety disorder NOS is proximately due to or the result of his Crohn's disease, for the following reasons. First, there is no consistent scientific evidence that Crohn's Disease physiologically causes anxiety. In other words, Crohn's disease is not a physiological etiology for anxiety. Second, the veteran's anxiety disorder is not temporally related to the onset of and diagnosis of his Crohn's disease while in the military. Third, the veteran did not receive any psychiatric treatment for anxiety while in the military and was not diagnosed with an anxiety disorder within 1 year of military service. However, the examiner failed to address whether the Veteran's acquired psychiatric disorder to include anxiety disorder is aggravated by his service-connected Crohn's disease. Where secondary service connection is asserted, an examination must offer an opinion as to aggravation in addition to direct causation. El-Amin, 26 Vet. App. at 140-41. In addition, in the February 2020 brief, the Veteran's attorney objected to the examiner's focus solely on a physiological link between anxiety and Crohn's disease, and failure to address whether the symptoms of Crohn's are the cause of anxiety. Specifically, the examiner did not address the Veteran's reports that he experiences anxiety about frequent and unpredictable episodes of loss of bowel control and arranges his life and activities around this worry. She also cited to two medical articles and stated that they link the symptoms of Crohn's Disease to anxiety. Thus, a remand is needed to address whether the Veteran's anxiety disorder is aggravated by his Crohn's disease, whether the Veteran's anxiety disorder is caused by his symptoms of Crohn's disease, and the relevant medical literature submitted by the Veteran. The articles are available as follows: "Crohn's Disease, Colitis Tied to Anxiety in Study" at https://www.webmd.com/ibd-crohns-disease/crohns-disease/news/20150804/crohns-disease-colitis-tied-to-anxiety-in-study; "Prevalence of Anxiety and Depression in Patients with Inflammatory Bowel Disease" at https://www.ncbi.nlm.nih.gov/pmc/5664260. The matters are REMANDED for the following action: 1. Obtain an opinion from an appropriate clinician addressing the Veteran's impairment of rectal sphincter control. After reviewing the claims file and the medical article cited in the February 2020 brief ("Perianal Crohn's Disease" available at www.ncbi.nlm.nih.gov/pmc/2780223), the clinician should answer: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's impairment of rectal sphincter control was caused by his Crohn's disease, including all symptoms of his Crohn's disease? (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's impairment of rectal sphincter control has been aggravated (worsened beyond its natural progression) by his Crohn's disease, including all symptoms of his Crohn's disease? (c.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's impairment of rectal sphincter control is itself a symptom of Crohn's disease? The opinions must discuss the medical article indicating anal crypts could be indicative of perianal disease. 2. Obtain an opinion from an appropriate clinician addressing the Veteran's anxiety disorder. After reviewing the claims file and the medical articles cited in the February 2020 brief ("Crohn's Disease, Colitis Tied to Anxiety in Study" at https://www.webmd.com/ibd-crohns-disease/crohns-disease/news/20150804/crohns-disease-colitis-tied-to-anxiety-in-study; "Prevalence of Anxiety and Depression in Patients with Inflammatory Bowel Disease" at https://www.ncbi.nlm.nih.gov/pmc/5664260), the clinician should answer: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's anxiety is caused by his Crohn's disease? (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's anxiety has been aggravated (worsened beyond its natural progression) by his Crohn's disease? (c.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's anxiety is due to symptoms of Crohn's disease, including episodes of loss of bowel control? The opinions must discuss the cited articles linking Crohn's disease to anxiety. (Continued on the next page) A complete, well-reasoned rationale must be provided for each and every opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Anthony L. Hines 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.