Citation Nr: 23066554 Decision Date: 12/18/23 Archive Date: 12/18/23 DOCKET NO. 18-47 831 DATE: December 18, 2023 REMANDED Entitlement to service connection for inflammatory bowel disease, to include ulcerative colitis, is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1971 to August 1974. Notably, the evidence shows the Veteran participated in toxic exposure risk activity (TERA), specifically herbicide exposure, during active service. See May 2023 TERA Memorandum. This matter is on appeal from an October 2016 rating decision that was issued in November 2016. In March 2023, the Board remanded this claim for additional evidentiary development and requested the agency of original jurisdiction (AOJ) afford the Veteran a VA examination and obtain an opinion that addressed if his inflammatory bowel disease (IBD) was caused or aggravated by an in-service injury, disease, or event, to include his acknowledged herbicide exposure. The Veteran was afforded a VA intestinal examination in June and September 2023 and diagnosed with ulcerative colitis. The June 2023 VA examiner explained that the evidence of record confirms a diagnosis of inflammatory bowel disease, specifically ulcerative colitis, which is a chronic disease that causes inflammation in the digestive tract. The June 2023 VA examiner noted that the exact cause of IBD is unknown but thought to be caused by a combination of genetic, environmental, and immune system factors. The examiner ultimately opined that the Veteran's IBS is not likely caused by the indicated TERA or herbicide exposure during service, noting that IBD is not a condition presumed to be associated with herbicide exposure. The September 2023 VA examiner also noted that the exact reason for ulcerative colitis is unknown but noted a few associated causes, including perfluoroalkyl or polyfluoroalkyl substances (PFAS) which are chemicals found in products, such as aqueous film forming foam used by civilian and military firefighters. The September 2023 VA examiner ultimately opined that the Veteran's IBD is not likely related to the indicated TERA or herbicide exposure and initially noted that the list of conditions presumed to be caused by herbicides does not include ulcerative colitis. However, the examiner noted the Veteran's report that he may have been exposed to PFAS during service but stated that it was difficult to establish his exposure, as the Veteran was not a military firefighter but was employed as a firefighter for 20 years after service. Nevertheless, the examiner noted that PFAS have been found in the water supply on some military bases and also stated that there might have been other toxic substances lurking on military bases during the last century that might contribute to the development of ulcerative colitis. The Board finds the September 2023 VA opinion is inadequate for the following reasons. First, the examiner did not address if the Veteran's IBD was caused by actual exposure to herbicides during service but, instead, relied on the fact that IBD or ulcerative colitis are not presumed to be related to herbicide exposure. In this regard, the Board also notes the examiner did not state if herbicide agents are the type of toxic substances that might contribute to the development of ulcerative colitis. Additionally, the examiner did not identify the military bases on which PFAS were found, which raises a question of whether the Veteran was stationed at any such bases. The Veteran's representative recently identified medical articles that may support a finding that strokes may aggravate colitis and also raised the question of whether the medications taken for his service-connected heart disability aggravates his inflammatory bowel disease, noting that the medications are known to cause gastrointestinal bleeding. See December 2023 brief. Given the evidence and arguments submitted by the Veteran's representative, the Board finds an addendum opinion is needed to further address the secondary service connection aspect of the Veteran's claim. In the December 2023 brief, the Veteran's representative also raised the issue of entitlement to a TDIU due to his claimed IBD disability. As a result, the TDIU claim is considered part and parcel and, thus, inextricably intertwined, with the claim being remanded herein. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Therefore, adjudication of the TDIU claim is deferred. The matter is REMANDED for the following action: 1. Identify whether the Veteran was exposed to perfluoroalkyl or polyfluoroalkyl substances (PFAS) which are chemicals found in products, such as aqueous film forming foam used by civilian and military firefighters while on active duty. 2. Arrange for an appropriate health care provider to review the claims file and provide an opinion as to the following: (a) Was the Veteran's inflammatory bowel disease, specifically ulcerative colitis, directly caused by or related to his acknowledged herbicide exposure during service? The reviewing healthcare provider is advised that the fact that ulcerative colitis is not on the list of conditions presumed to be related to herbicide exposure cannot form the basis of an opinion on direct service connection. The examiner is asked to review the opinion provided in September 2023 and address (a) if herbicide agents are the type of toxic substances that might contribute to the development of ulcerative colitis and (b) if the Veteran is found to be exposed to such, whether PFAS are the type of toxic substances that might contribute to the development of ulcerative colitis. (b) The examiner should indicate whether the Veteran's inflammatory disease/ulcerative colitis was (1) caused or (2) aggravated beyond its normal progression by the service-connected coronary artery disease, to include any medications taken therefor. In answering the foregoing, the reviewing healthcare provider is asked to consider the evidence identified and arguments proffered in the December 2023 brief submitted by the Veteran's representative. Aggravation means an increase in disability - any additional impairment of earning capacity - of the nonservice-connected disability. Aggravation also includes situations where the claimed disability would be less severe and result in less functional impairment but for the service-connected disability because the service-connected disability results in the inability to treat the claimed disability. If aggravation is found, the reviewing healthcare provider must attempt to establish a baseline level of severity of the diagnosed disability prior to aggravation by the service-connected disability. If the reviewing health care provider finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished. A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Turnipseed, 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.