Citation Nr: 23046244 Decision Date: 08/21/23 Archive Date: 08/21/23 DOCKET NO. 19-31 525A DATE: August 21, 2023 REMANDED Service connection for a gastrointestinal disorder, to include irritable bowel syndrome (IBS) and Crohn's disease. ? REASONS FOR REMAND The Veteran served on active duty from May 2000 to April 2004. The case is on appeal from an August 2018 rating decision. In November 2022, the Veteran testified at a Board hearing. In December 2022, the Veteran submitted additional evidence. Service connection for a gastrointestinal disorder, to include IBS and Crohn's disease. The Veteran's contends that he has Crohn's disease related to in-service exposure to environment hazards while deployed in the Southwest Asia (SWA). Also, the Board notes that the evidence raises IBS as a potential issue. He further seeks service connection for IBS and Crohn's disease as undiagnosed illnesses or a medically unexplained chronic multi-symptom illness (MUCMI) due to exposure to Gulf War environmental hazards. In a November 2017 claim form, the Veteran reported that his chronic Crohn s disease is a result of in-service exposure to polluted waters and/or sewage runoff while serving as a scuba diver in Iraq's Khawr Abd Allah water way in port of Umm Qasr, the Northern Arabian Gulf, and Hawaii and American Samoa. In a correspondence, he reported being exposed to "foul" water as a diver in Iraq and "other stations." He also reported continuing treatment for Crohn's disease symptoms. The Veteran submitted an April 2003 article on the United States Coast Guard (USCG) Walnut, a buoy tender, and its operations in the Persian Gulf. The article names the Veteran and describes the USCG Walnut's missions in SWA and Hawaii, including defending from environmental terrorism, protecting fishing grounds, decrease oil releases into the Persian Gulf, and transporting aid shipment in the Iraqi waterways. In a September 2018 notice of disagreement (NOD), the Veteran reported that he developed intestinal symptoms in service which have continued since then. In an October 2019 Form 9, the Veteran reported that when he was diagnosed with anal fissures while in the Arabian Gulf and that a care provider told him it could be early signs of Crohn's disease. He also reported that a care provider wrote that a foul water in Iraq may have been a factor contributing to Crohn's disease. Moreover, he reported being underweight and experiencing gastric symptoms, including bleeding, diarrhea, and several bowl movements a day, for years after leaving service. At the November 2022 Board hearing, the Veteran reported diving in "dirty water." He explained that he was not exactly aware of "what was in the water." He described being in "pitch black conditions, while scuba diving" and water getting into his nostrils. He reported that in 2003 while in Iraq, he noted bright red blood stools for which he sought treatment in a Naval base where a provider diagnosed him with anal fissures. In 2014, he was diagnosed with Crohn's disease. He explained that he never underwent a full, or detailed, in-service physical examination for gastrointestinal symptoms. He indicated that when he filled out the in-service questionnaire regarding toxic exposure, he was not aware that he was exposed to "anything that may have threatened my health." He reported reoccurring bright red blood in stools. Moreover, the Veteran reported travelling abroad shortly after service and experiencing gastrointestinal symptoms, including severe diarrhea, weight loss, and red stools. He reported using the bathroom ten times a day. Also, he reported that the gastrointestinal disorder affects his daily routine "extremely." While he is able to work as a firefighter, he experiences anxiety as he tries to ensure that he has a place to use the restroom in case of an emergency. Also, he reported that he takes sick days during flare-ups of the symptoms. He is on medication and cautious of what he eats. The Veteran's service personnel records (SPRs) show that he received training as a scuba diver and was assigned to USCGC Walnut in Honolulu, Hawaii. Also, the SPRs show that the Veteran received the USCGC Achievement and Unit Commendation Medals for is service in the USCGC Walnut from November 2000 to March 2004. Particularly, the awards note that the Veteran completed 55 dives in the Northern Arabian Gulf and also that his assigned post established a navigational channel in Khawr waterway to the port of Umm Qasr. A dive log shows that he completed multiple dives in Hawaii, Saudi Arabia, and the Persian Gulf. The Veteran's service treatment records (STRs) show that he was treated for intestinal symptoms. An October 2001 diver physical shows no reports of or treatment for gastrointestinal disorders. A February 2003 medical record shows that the Veteran reported blood in stools from the night before. He also reported experiencing dark red blood in stools for about a year and loose stools. A March 2003 primary care note shows that he was diagnosed with anal fissures. A subsequent medical record is noted as "possible fissure, resolved." A June 2003 post-deployment examination shows that the Veteran marked that he served in SWA, including Kuwait and Iraq from February 2003 to May 2003 as a quartermaster on a ship. He reported going to sick call once. He denied exposure to pollutants, toxins, chemicals, pesticides, or herbicides. While he reported going to sick call once, he did not report gastrointestinal symptoms. The Veteran reported being in excellent health. He marked "no" to any medical problems that developed during deployment. He denied concerns about possible exposures or event during deployment that may affect his health. A separation examination is not of record at this time. The Veteran's post-service private treatment records show that he was treated for gastrointestinal symptoms. A January 2014 private care provider letter notes that the Veteran visited Mexico in October 2013 and developed persisting symptoms, including discomfort, gaseousness, diarrhea, and weight loss. The provider also noted that while the Veteran is in good health, he was exposed to foul water in Desert Storm while in service. A February 2014 private provider letter shows that he diagnosed the Veteran with Crohn's disease and prescribed medication. The Veteran's post-service VA treatment records show that he was treated for Crohn's disease symptoms. A November 2017 VA provider letter shows that the Veteran was found to have chronic colitis after undergoing a colonoscopy. A February 2018 gastroenterology note shows that the Veteran was being examined for IBS. The findings revealed that the Veteran had abnormal vascular changed and erythema. In February 2018, the Veteran was afforded a VA examination for Crohn's disease. The examining physician diagnosed the Veteran with Crohn's disease provided a negative nexus opinion. He noted that Crohn's disease is structural disease that is not presumptive Gulf War related conditions. In December 2022, the Veteran submitted an October 2022 examination in which a private care provider diagnosed the Veteran with IBS since 2003 and Crohn's disease since 2014. She opined that the Veteran's Crohn's disease more likely than not began during service when the Veteran initially began experiencing blood in the stools. Also, she opined that IBS more likely than not is attributable to in-service toxic exposures while deployed in SWA. In December 2022 and January 2023, VA memoranda was associated to the claims. The RO confirmed that the Veteran served in the SWA theater of operations in Bahrain from February 2003 to May 2003. He was found to be a Persian Gulf Veteran, under 38 U.S.C. § 1117 and have service that constitutes presumptive toxic exposure, under 38 U.S.C. § 1119. The Board finds a remand is warranted to obtain VA examinations to clarify the diagnosis of his disabilities and to address the etiology of his disabilities. As to IBS, the Board finds that a remand is warranted for a VA examination. In this regard, the evidence raise the possibility that the Veteran may warrant service-connection for IBS. He submitted the October 2022 private medical opinion showing a diagnosis of IBS. IBS is a functional gastrointestinal disorder. See 38 C.F.R. § 3.317 (a)(2)(i)(3). It is a MUCMI. The Veteran's STRs, previous private treatment records, VA treatment records, and February 2018 VA examination do not contain a diagnosis of IBS. While the Veteran was examined for IBS as shown by a February 2018 record, there was no diagnosis of IBS. The Board needs to know whether the Veteran has a current diagnosis of IBS (as of 2003). Additionally, as the Veteran served in SWA, a description of the symptoms is needed. For the purposes of establishing presumptive service connection based on Gulf War service, the evidence needs to show that it manifested during service in SWA, or meets the criteria for a 10 percent rating. See 38 C.F.R. § 3.317(a)(1)(i). The Veteran as yet to receive a VA examination that addresses IBS. The current evidence meets the low threshold of evidence needed to provide the Veteran a VA examination for IBS, and a VA examination is warranted. See McLendon v. Nicholson, 20 Vet. App. 79, 81(2006). Also, the Board finds that the February 2018 VA medical opinion for the Veteran's Crohn's disease is conclusory and does not actually provide an opinion as to the etiology of Crohn's disease. Additionally, the examiner does not address and discuss the Veteran's STRs, SPRs, specific occupation as a scuba diver in the USGC Walnut, deployment to SWA, and reports of onset and symptomatology. Moreover, while the Veteran's Crohn disease is not presumptive under the provisions of 38 C.F.R. § 3.317, the evidence raises the possibility that service connection can be established under 38 U.S.C. § 1168. The evidence shows that he was determined to have presumptive toxic exposure and a Persian Gulf War Veteran. Also, he has claimed that a non-presumptive condition is due to exposure to toxins, or in conditions involving toxic exposure activity (TERA). See 38 U.S.C. § 1168. Under the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), effective from August 10, 2022, Section 303 implemented 38 U.S.C. § 1168, requiring a disability examination and medical opinion be requested for certain non-presumptive conditions involving TERA. For such claims, VA is required to provide a disability examination and medical opinion when the Veteran submits a claim for compensation, has evidence of a disability, had evidence of participation in a TERA and such evidence is not sufficient to establish service connection for the disability. Here, the Veteran has claimed that Crohn's disease is related to his participation in a TERA, yet the Veteran has not been provided with a TERA specific examination. The current evidence is not sufficient to establish service connection for the disability. As such, a remand is warranted to obtain a new VA medical opinion for Crohn's disease. On remand, updated VA treatment records should be associated to the claims file. The claims are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from since April 2018. 2. Also, obtain the Veteran's complete STRs, with an emphasis on locating the Veteran's separation examination. If VA determines that further efforts to locate these records would be futile, the Veteran and his representative must be notified, and a formal finding of unavailability must be associated with the claims file. 3. Schedule the Veteran for a VA examination for an appropriate clinician to determine the nature and etiology of any IBS. The claims file should be reviewed by the examiner, including a copy of this remand. Then, the examiner is asked to address each of the following questions: (a.) State whether the Veteran has a diagnosis of IBS. (b.) If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: (c.) Is it at least as likely as not that the Veteran has or has had IBS at any time during the pendency of the appeal? The examiner's attention is directed to October 2022 private examination showing a diagnosis of IBS and noting the year "2003." The examiner is advised that the Board needs to know whether the Veteran has a current diagnosis of IBS (as of 2003) and what other gastrointestinal diagnoses are present. If any diagnoses are duplicative or ruled out, it should be clearly explained why that is so. (d.) If the Veteran does not have IBS, is any current chronic gastrointestinal disorder considered a functional gastrointestinal disorder (as opposed to a structural gastrointestinal disorder)? (e.) If it is not a functional gastrointestinal disorder, is any current chronic gastrointestinal disorder at least as likely as not related to service, including scuba diving in Southwest Asia? (f.) If so, is the Veteran's disability pattern consistent with: (1) an undiagnosed illness; (2) a diagnosable but medically unexplained chronic multisymptom illness (MUCMI) of unknown etiology or pathophysiology, (3) a diagnosable chronic multisymptom illness with a partially explained etiology and pathophysiology, or (4) a disease with a clear and specific etiology and diagnosis. An illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive. It is not a MUCMI where both the etiology and the pathophysiology of the illness are partially understood. The determination of whether a condition is a MUCMI must be based on an individual's circumstances rather than the illness as it is understood in the general public. Therefore, in answering this question, the rationale must be specific to this Veteran and address BOTH the etiology and the pathophysiology of this Veteran' s illness. (g.) If the Veteran's disability pattern is (1) an undiagnosed illness, (2) a MUCMI, or (3) a disease with a clear and specific etiology and diagnosis, provide an opinion as to whether it is at least as likely as not related to environmental exposures experienced by the Veteran during service in Southwest Asia. (h.) Is it at least as likely as not that any diagnosed disorder had its onset directly during the Veteran's service or is otherwise causally related to any event or circumstance of his service, including environmental exposures during service in Southwest Asia during the Persian Gulf War? 4. Schedule the Veteran for a TERA specific VA examination pursuant to the provisions of 38 U.S.C. § 1168 to determine the current nature and likely etiology of the Veteran's gastrointestinal disorder, including Crohn's disease. The claims file should be reviewed by the examiner, including a copy of this remand. Then, the examiner is asked to address each of the following questions: Whether the Veteran's gastrointestinal disorder including Crohn's disease, is at least as likely as not related to or otherwise caused by toxic exposure risk activities, including as a scuba diver in Southwest Asia in the USCG Walnut from February 2003 to May 2003? The examiner is asked to consider that the Veteran has been determined to be Persian Gulf Veteran and have presumptively toxic exposed in while deployed to Bahrain in Southwest Asia from February 2003 to May 2003. Also, the examiner is asked to consider the Veteran's reports of onset and symptomology, particular scuba diver occupation, particular deployment history, February 2003 and March 2003 STRs, submitted article regarding the Veteran and USCG Walnut and its environment missions in the Southwest Asia and Hawaii. A rationale for all opinions expressed should be provided. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Nevarez-Myrick, Nancy 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.