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Requesting Nexus Help: PTSD and IBS


Fellow Veterans and Supporters,

I had a C&P for IBS on 10/5/2018, which the results now posted on Healthevets. I am SC for PTSD at 70% and it is rated as permanent. I have been struggling with issues surrounding IBS for many years and submitted a claim back in September. My GI doc and PCP are both in agreement that the IBS is a result of PTSD, unfortunately the GI doc does not complete FMLA or Disability forms but rather send it back to the PCP to do. So when I presented my records it is now a physician vs physician. The C&P doc wrote this:

The etiology of Irritable bowel syndrome (IBS) is thought to include
combinations of gut-brain axis problems, gut motility disorders, pain
sensitivity, infections, including small intestinal bacterial overgrowth,
neurotransmitters, genetic factors, and food sensitivity. PTSD is not
considered the etiology.

I wanted to compile VA case law showing this is not the case, but could not find anything. Could someone point me in the right direction? Or, in this situation, what is the best course of action as the claim is still processing?

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If you have a doctor that states your IBS is at least as likely as not the result of your PTSD it is doctor against doctor.  The good news is that the VA is supposed to give the benefit of the doubt to the veteran.  As the BVA wrote when they awarded my neuropathy "the tie goes to the runner".  You can only find VA case law at the COVA level.  What you could do is research BVA cases for IBS and PTSD and see if any cross paths and the regulations that were cited in the cases.  It is a time consuming task but one that could possibly help you.  That is how I found references that I used to challenge my case.


Edited by vetquest

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I agree with Vetquest.  If doctors do not agree on the etiology, the VA can:

1.  Decide on one docs opinion or the other.  They can do this, but must give a reasons and bases for doing so.   For example, the VA can decide one doctors opinion is more thorough than the other, say if Doc A had been your doc for 15 years, and doc b had been your doc for 15 minutes.  

     Also plausable, as Vetquest explained, is that the doctors opinions are in equipose, and the tie should go to the Vet.  

2.  Sometimes the VA, when there are conflicting etiologies, can ask for still another C and P exam to clarify.  Then you would have 3 opinions and 2 of the 3 should prevail.  

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Citation Nr: 1730452	
Decision Date: 07/27/17    Archive Date: 08/09/17

DOCKET NO.  14-27 194	)	DATE

On appeal from the
Department of Veterans Affairs Regional Office in Seattle, Washington


Entitlement to service connection for ulcerative colitis, to include as secondary to service connected posttraumatic stress disorder (PTSD).  


Veteran represented by:	Veterans of Foreign Wars of the United States


The Veteran


EM Lederman, Associate Counsel


The Veteran had active duty service in the United States Army from January 1959 to August 1970 and from August 1971 to June 1982.  

This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah.  Jurisdiction was subsequently transferred to the RO in Seattle, Washington.  

The Veteran testified at a Travel Board Hearing before the undersigned Veterans Law Judge in January 2017.  A transcript of the hearing is of record.  

In June 2017, the Board requested a Veterans Health Administration (VHA) opinion.  38 C.F.R. § 20.901(a).

This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016).  38 U.S.C.A. § 7107(a)(2) (West 2014).


The Veteran's ulcerative colitis is proximately due to his service-connected PTSD.


The criteria for secondary service connection for ulcerative colitis are met.  
38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.310(a) (2016).


The Veteran seeks service connection for ulcerative colitis, both on a direct basis and as secondary to PTSD.  As secondary service connection is warranted, only that theory of entitlement will be addressed herein.

Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury.  38 C.F.R. 
§ 3.310(a).  Secondary service connection may also be established for a nonservice-connected disorder that is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 
See 38 C.F.R. § 3.310 (b); Allen v. Brown, 7 Vet. App. 439, 448 (1995).

To prevail on the issue of secondary service causation, the record must show: (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability.  Wallin v. West, 11 Vet. App. 509, 512 (1998).

Here, the Veteran is diagnosed with ulcerative colitis.  See March 2016 VA examination report.  He is also service-connected for PTSD.  Thus, the first two elements of secondary service connection are established.  

Regarding element three, nexus, there is one competent opinion of record addressing secondary service connection.  Specifically, in a June 2017 opinion, a VHA expert gastroenterologist concluded that the Veteran's ulcerative colitis has been aggravated by his PTSD.  In support of his opinion, the expert reasoned that stress may have a role in the exacerbation of symptoms in patients with known irritable bowel disease (IBD), and emphasized that the Veteran reported frequent symptom flare-ups and his physicians noted difficulty managing his ulcerative colitis.  The gastroenterologist noted that "[s]tress has been implicated in the activation of the enteric nervous system and elaboration of proinflammatory cytokines."  

While the June 2017 VHA expert gastroenterologist ultimately concluded that the Veteran's ulcerative colitis has been "aggravated" by his PTSD, the Board finds sufficient evidence to award secondary service connection on a proximate cause basis under 38 C.F.R. § 3.310(a).  Specifically, in addressing secondary service connection, the VHA expert stated that "[s]tudies examining an association between psychological factors (in this case PTSD) and the risk of developing IBD have yielded inconsistent results" - in other words, some studies have supported such a relationship, while others have not.  Jackson v. Virginia, 443 U.S. 307, 319 (1979) (stating it is 'the responsibility of the trier of fact fairly to . . . draw reasonable inferences from basic facts to ultimate facts"); Bastien v. Shinseki, 599 F.3d 1301, 1306 (Fed. Cir. 2010) ("The evaluation and weighing of evidence and the drawing of appropriate inferences from it are factual determinations committed to the discretion of the fact finder.").  The Board will afford the Veteran the benefit of the doubt in this regard.  38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102.  Therefore, secondary service connection for ulcerative colitis is established.


Secondary service connection for ulcerative colitis is granted. 





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Good find Mdash1.

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