Citation Nr: A25028989 Decision Date: 03/28/25 Archive Date: 03/28/25 DOCKET NO. 250303-514806 DATE: March 28, 2025 ORDER Service connection for irritable bowel syndrome (IBS) as secondary to post-traumatic stress disorder (PTSD) is granted. Service connection for gastroesophageal reflux disease (GERD) as secondary to PTSD is granted. FINDINGS OF FACT 1. There is at least an approximate balance of positive and negative evidence as to whether the Veteran's IBS is aggravated by his service-connected PTSD. 2. There is at least an approximate balance of positive and negative evidence as to whether the Veteran's GERD is aggravated by his service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for IBS as secondary to PTSD have been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for GERD as secondary to PTSD have been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army December 1967 to December 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2024 Appeals Modernization Act (AMA) rating decision that considered the evidence of record on that date. In a March 2025 VA Form 10182, the Veteran requested Board review of the August 2024 rating decision under the evidence review docket. Under evidence review, a Board decision is based on the evidence at the time of the prior decision, as well as evidence submitted by a claimant or their representative within 90 days of the election to appeal to the Board. 38 C.F.R. § 20.303. Accordingly, the Board may only consider the evidence of record as of August 20, 2024, the date of the rating decision on appeal, as well as any evidence submitted by the Veteran or his representative between March 3, 2025, and June 1, 2025. The Board recognizes that in March 17, 2025, correspondence, the Veteran, through his representative waived the remaining time to submit additional evidence in support of his claim. Therefore, the Board will proceed with adjudication at this time. The Board notes that evidence was added to the claims file during a period of time when such new evidence would not be allowed to be considered. Therefore, the Board may not consider this evidence. 38C.F.R. §20.300. The Veteran, however, may file a Supplemental Claim at a future date and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. Please note that the case has been advanced on the docket pursuant to 38 C.F.R. § 20.900 (c). Legal Criteria for Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, 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)). Service connection may also be granted for disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Further, service connection may be warranted for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (a). Secondary service connection requires (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). A disability deemed proximately due to or the result of a service-connected disease or injury shall be service connected ("secondary service connection"). 38C.F.R. §3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 1. Service connection for irritable bowel syndrome (IBS) as secondary to post-traumatic stress disorder (PTSD) is granted. AND 2. Service connection for gastroesophageal reflux disease (GERD) as secondary to PTSD is granted. The Veteran is claiming service connection for IBS and GERD, claiming these conditions had their onset in and have continued since his active-duty service. Alternatively, the Veteran contends that his gastrointestinal disabilities are related to his already service-connected PTSD. Specifically, in March 2025 correspondence, the Veteran's representative argued that his IBS and GERD were worsened by his PTSD. Initially, the Board notes that the August 2024 rating decision includes the favorable findings that the Veteran was diagnosed with IBS and GERD. Thus, the Board is bound by these favorable findings, and the Veteran meets the current disability requirement. See 38 C.F.R. § 3.104(c). Turning to the evidence of record, the claims file contains a December 2022 letter from Dr. A.T., one of the Veteran's treating providers at a VA facility. Dr. A.T. wrote that the Veteran suffered from gastrointestinal issues, consistent with IBS. The provider explained that medical literature supports a high prevalence of gastrointestinal symptoms in patients with PTSD, and therefore it was his professional opinion that the Veteran's gastrointestinal symptoms were associated with his PTSD. In January 2023, VA medical examinations and opinions were added to the claims file. The examiner opined that it was less likely than not that the Veteran's GERD and IBS were related to this service-connected PTSD, as there is no medical literature that supports a causal relationship between PTSD and GERD or IBS. The examiner also noted that the Veteran experienced both GERD and IBS prior to being diagnosed with PTSD, and therefore these conditions were not the result of the service-connected condition. The Veteran was afforded new VA examinations and medical opinions in September 2023. The Veteran reported that his GERD and IBS both had their onset in 1967, while he was deployed in Vietnam. The Veteran reported his belief that his GERD was related to his IBS, and that both of these conditions were triggered by stress and anxiety related to his PTSD. The VA examiner opined that it was at least as likely as not that the claimed gastrointestinal disabilities were due to the service-connected GERD, as these conditions began subsequent to the PTSD and are a direct result of PTSD. Specifically, as it relates to IBS, the examiner explained that because PTSD can cause hyperarousal and hypervigilance, this can signal to the gut to function in the hyperarousal state, which may cause constipation and diarrhea. As it relates to GERD, the examiner explained that because GERD can occur when the symptoms of PTSD, such as anxiety, depression and stress, lead to an overproduction in stomach acid. Therefore, the examiner determine that the medical literature supported a nexus between the claimed disabilities and the PTSD. VA medical opinions were added to the claims file in January 2024. At that time, the examiner opined that it was less likely than not that the claimed disabilities were proximately due to or the result of PTSD. The examiner explained that the Veteran was diagnosed with his GERD and IBS in 2006 and 2011, respectively, and was diagnosed with PTSD in 2019. The examiner stated that while the September 2023 VA medical opinions provided a positive nexus for secondary service connection, the examiner failed to take into consideration that the Veteran was diagnosed with GERD and IBS prior to being diagnosed with PTSD. The examiner also stated, without further explanation, that there was no objective evidence in the claims file that the IBS or GERD were aggravated by the service-connected PTSD. In May 2024, new VA medical examinations and opinions were added to the claims file. The VA examiner opined that it was less likely than not that the claimed disabilities were proximately due to or the result of PTSD. The examiner's rationale was that based on a review of the medical evidence and known pathologies of the disorders, the Veteran's PTSD has not been established as being an etiological agent in the development of IBS or GERD. In March 2025, during an open evidentiary window, additional medical evidence was added to the claims file. In a November 2024 private opinion, Dr. M.K. explained that while he saw clear links and relationships between the claimed disabilities and PTSD, there is not a clear causal relationship. The examiner explained that the Veteran is instead claiming that his PTSD has aggravated and worsened his GERD and IBS, as related to the Veteran's triggering war recollections. Dr. M.K. opined that, based on his medical expertise and research, there was at least a 50 percent probability that the Veteran's ongoing gastrointestinal symptoms had a secondary relationship to his PTSD. In weighing the medical opinions of record, the Board first looks to the January 2024, January 2024 and May 2024 VA examinations. The Board notes that while the VA examiners generally stated that there was no causal relationship between IBS and GERD and the Veteran's service-connected PTSD, the examiners failed adequately address whether the IBS and/or GERD were aggravated by the Veteran's PTSD. The January 2023 and May 2024 VA examiners, while addressing the question of causation, did not address the question of aggravation at all. However, a secondary service connection claim has two prongs: causation and aggravation. 38 C.F.R. § 3.310. To be adequate, a VA opinion must provide separate rationales for both causation and aggravation. See Atencio v. O'Rourke, 30 Vet. App. 74 (2018). Further while the Board recognizes that the January 2024 examiner stated that there was no objective evidence to support that the claimed IBS or GERD were aggravated by the PTSD, the examiner did not provide any supporting rationale for this opinion. Importantly, the VA examiners failed to consider or discuss the Veteran's specific assertions that both of these conditions were triggered by stress and anxiety related to his PTSD. For these reasons, the Board finds these opinions inadequate for adjudication purposes. In consideration of the remaining medical opinions of record, the Board notes that the private examiners who rendered the December 2022 and November 2024 opinions, were both competent to opine as to the etiology of the Veteran's GERD and IBS. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159 (a)(1). As explained above, the December 2022 examiner found that the medical literature supported that there was a high prevalence of gastrointestinal symptoms in patients with PTSD. Additionally, the November 2024 examiner found that based on his medical experience and research, the GERD and IBS were at the very least aggravated by the service-connected PTSD. This is significant, especially in light of the September 2023 VA medical opinion, which found that the symptoms of PTSD can trigger physiological responses which trigger symptoms of IBS and GERD. All of the opinions offered were competent and probative as they were rendered after and in light of the Veteran's history and with consideration of medical principles by licensed medical professionals. Thus, based upon the foregoing and resolving reasonable doubt in favor of the Veteran, the Board finds that there is at least an approximate balance of positive and negative evidence as to whether the Veteran's GERD and IBS disabilities are related to his service-connected PTSD, via aggravation. See Lynch v. McDonough, 999 F.3d 1391, at 1395 (Fed. Cir. 2021). As such, service connection for GERD and IBS is warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. As the Board has granted secondary service connection it need not address direct service connection, or any other theories for service connection, in this matter. Ardie A. Bland Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Nettey, 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.