PERITONEAL ADHESIONS

Summary

The Veteran served on active duty from August 2001 to June 2004. The Veteran appealed the denial of service connection for adhesions, claimed as secondary to irritable bowel syndrome (IBS). The Board reviewed the evidence, including Service Treatment Records (STRs), a November 2020 VA Intestinal examination, and private treatment records. The STRs at separation showed no signs, symptoms, or complaints of adhesions, with a normal abdominal examination. The Veteran's private treatment records from October 2020 indicated a diagnosis of intraabdominal adhesions, but the Board found this onset was remote from service. The Board noted that IBS is not currently service-connected, which is a prerequisite for secondary service connection. The Board also considered the Veteran's lay statements regarding abdominal pain but found them outweighed by the medical evidence, which indicated a remote onset of the condition. The Board concluded that adhesions were not manifest in service, not incurred or aggravated by service, and not proximately due to or the result of any service-connected disability. Therefore, service connection for adhesions was denied.

Rationale

No evidence of adhesions or residuals in service; No nexus to service or service-connected disability; IBS is not service-connected, precluding secondary claim

Full Decision Text

Citation Nr: A26040663
Decision Date: 04/30/26	Archive Date: 04/30/26

DOCKET NO. 210616-166404
DATE: April 30, 2026

ISSUE

Entitlement to service connection for adhesions, as secondary to irritable bowel syndrome

ORDER

Entitlement to service connection for adhesions, as secondary to irritable bowel syndrome is denied.

FINDING OF FACT

Adhesions were not manifest in service or within one year of separation, are not caused or aggravated by a service-connected disease or injury, and are not otherwise attributable to service.

CONCLUSION OF LAW

Adhesions were not incurred in or aggravated by service, may not be presumed to have been incurred therein, and are not proximately due to, the result of, or aggravated by service connected disease or injury.  38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from August 2001 to June 2004. 

This matter is before the Board of Veterans Appeals (Board) on appeal from a May 2021 Appeals Modernization Act (AMA) rating decision by the Department of Veterans Affairs (VA) Regional Office (RO).  The rating decision considered the evidence of record on that date.  The Board is bound by the favorable findings.  See 38 C.F.R. § 3.104(c).  The Veteran timely appealed this decision to the Board by requesting the AMA Hearing docket.

In October 2024 the Veteran withdrew her hearing request.  Her representative writes that "she no longer wanted a BVA hearing of any kind."  The scheduled hearing was withdrawn and the claim will be considered on the merits below.

Duties to Notify and Assist

The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance.  38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a).

In the VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) (NOD), the Veteran elected the Hearing option; therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the appellant or his or her representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a).  By withdrawing her hearing request she removed one avenue for contributing additional lay or other evidence to the claims file for appellate review.

The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim.  See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct. 3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board).

The Board has reviewed all of the evidence in the Veteran's claims file.  Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on her behalf be discussed in detail.  Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim.  See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000).

Entitlement to service connection for adhesions, as secondary to irritable bowel syndrome

To establish service connection a Veteran must generally show: "(1) the existence of a present disability; (2
 Veteran or obtained on her behalf be discussed in detail.  Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim.  See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000).

Entitlement to service connection for adhesions, as secondary to irritable bowel syndrome

To establish service connection a Veteran must generally 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."  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).  Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303 (d).

For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic."  When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity.  Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned.  When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim.  38 C.F.R. § 3.303 (b).  

Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected.  When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition.  38 C.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.  However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury.  38 C.F.R. § 3.310 (b).

For certain chronic diseases, additional presumptive theories of entitlement are relevant in addition to direct service connection.  See 38 C.F.R. §§ 3.303, 3.307, 3.309.  Under 38 C.F.R. § 3.303 (b), service connection may be established by demonstrating continuity of symptomatology.  Continuity may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology.  The provisions of 38 C.F.R. § 3.303 (b) only apply to diseases recognized by VA as "chronic."  See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303 (b), 3.309(a).  Chronic diseases that become manifest to a degree of 10 percent or more within one year of termination of active duty may be presumed to have been incurred in service.  38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309.

VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits.  38 U.S.C. § 1154 (a).  Lay evidence can be competent and sufficient to establish a diagnosis of a condition when
 2013); 38 C.F.R. §§ 3.303 (b), 3.309(a).  Chronic diseases that become manifest to a degree of 10 percent or more within one year of termination of active duty may be presumed to have been incurred in service.  38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309.

VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits.  38 U.S.C. § 1154 (a).  Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.  Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).

Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence.  Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006).  However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements.  Id.  The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc.  Id.  Further, a negative inference may be drawn from the absence of complaints for an extended period.  See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom.  Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000).

By way of background, the Service Treatment Records (STRs) include a March 2004 Report of Medical History from months before separation.  The Veteran indicated in the negative for frequent indigestion and heart burn.  The contemporaneous Report of Medical Examination disclosed a clinically normal evaluation of the abdomen and viscera.  There is a notation of NE for the anus and rectum.  There are no signs, symptoms, or complaints of adhesions at separation. 

Next, the Veteran was afforded an assortment of VA examinations, including a November 2020 VA Intestinal examination.  This was primarily obtained in the context of other appeals.  Still, it shows no indication for peritoneal adhesions.  There are indications of emergency repair of bowel perforation, resection of the large intestine, and a lay history of IBS with constipation that was resistant to treatment. 

Years later, the May 2021 rating decision favorably found remote disability, but no nexus to service or service-connected disability.  The RO favorably found, "You have been diagnosed with a disability. Your private treatment records from Singing River hospital dated October 9, 2020 show a diagnosis of dense intraabdominal adhesions."  

Additional treatment records are substantially the same.

The Veteran contends that she is entitled to service connection for adhesions, as secondary to irritable bowel syndrome.

In making all determinations, the Board must fully consider the lay assertions of record.  A layperson is competent to provide "evidence not requiring that the proponent have spec`ialized education, training, or experience."  38 C.F.R. § 3.159 (a)(2).  "Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person."  See id.  A layperson is also competent to report on the onset and continuity of their current symptomatology.  See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge).  When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).  Here, the Veteran has related a competent diagnostic impression of adhesions in the private records, but the remaining element of service connection is a nexus to service.


 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge).  When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).  Here, the Veteran has related a competent diagnostic impression of adhesions in the private records, but the remaining element of service connection is a nexus to service.

Here, the most probative evidence is the contemporaneous treatment records, including the Service Treatment Records (STRs).

Unfortunately, the STRs do not show any signs, symptoms, or complaints of adhesions or their residuals at separation.  Any notations in the earlier STRs of abdominal discomfort and diarrhea are not necessarily diagnosed as chronic adhesions.  The Board notes other factors, including claimed IBS still on appeal. 

More than one decade after separation, private treatment records show what the RO later accepted as diagnosed intraabdominal adhesions. 

While on appeal the Veteran has not identified or submitted any evidence that would suggest the Board should reach a different outcome than already arrived at by the RO.  There is still no nexus to service.

Regarding direct and presumptive service connection, the Board finds that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service.  Adhesions were not manifest in service or within one year from separation, and are not otherwise attributable to service.  There is no probative evidence to the contrary.  In addition, the Board finds that while competent to report by a physician that she has a diagnosis of adhesions, the Veteran's lay opinion identifying a chronic disease pales in probative weight when compared to the objective medical evidence of record.  Additional causal evidence against the claim, and while not dispositive, is the lapse of so many years between discharge and the first documented reports of a chronic condition many years after discharge.  This multi-year gap after service provides highly probative evidence against the claim.  See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000).  

An alternative method of establishing the second and third Shedden element, under 38 C.F.R. § 3.303 (b), is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309 (a).  Consideration of entitlement to service connection via the demonstration of continuity of symptomatology is applicable in the present case.  However, the most probative evidence in the contemporaneous treatment records establishes the remote onset of the claimed disease entity long after separation.  Therefore, we find that service connection on a direct and presumptive basis for adhesions is not warranted.  

Next, the Veteran's theory of entitlement to service connection for adhesions is also for secondary service connection.  More specifically, she contends that adhesions are secondary to IBS and functional impairment.  38 C.F.R. § 3.310.  The Board has considered the evidence of record, and finds that adhesions are not related to service, and are less likely than not proximately due to, the result of, or aggravated by any service-connected disability.  IBS is not service-connected and so this avenue fails as a matter of law.  See Sabonis v. Brown, 6 Vet. App. 426 (1994) (where the law is dispositive, the claim must be denied due to a lack of legal merit).  There is no other competent and probative evidence establishing that adhesions are due to any service-connected disease or injury. 

The Board also considered the Veteran's lay statements to the extent that she is competent to relate current pain in the abdomen.  However, they are outweighed by the medical evidence of record.  In this regard, the Board considered that Saunders clarified that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability.  See Saunders v. Wilkie, 886 F.3d 1356 (2018).  The United States Court of Appeals for the Federal Circuit (Federal Circuit) found that the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability."  The Board observes that Saunders does not
 they are outweighed by the medical evidence of record.  In this regard, the Board considered that Saunders clarified that evidence of pain alone which results in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability.  See Saunders v. Wilkie, 886 F.3d 1356 (2018).  The United States Court of Appeals for the Federal Circuit (Federal Circuit) found that the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability."  The Board observes that Saunders does not eliminate the need for underlying pathology, disease, or injury (also sometimes called a diagnosis).  In the appeal at bar there is no additional functional impairment due to pain alone as is addressed by Saunders that is related to service or service-connected disability.  Therefore, even after considering Saunders, service connection for adhesions is not warranted.

In denying this appeal without a separate VA examination, it is longstanding principle that VA is not required to provide a medical examination when there is no credible evidence of an event, injury, or disease in service.  See Bardwell v. Shinseki, 24 Vet. App. 36 (2010).  Moreover, a conclusory generalized lay statement that service event or illness caused the claimant's purported disability is insufficient to require the Secretary to provide an examination.  See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010).  The Board has considered the Veteran's sincere belief that the benefit sought is warranted.  The first documented complaints and application for service connection are from several years after service.  See generally Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).  

In sum, the Board assigns the most probative weight to the contemporaneous medical records, including the STRs and treatment records.  The Board considered direct service connection and theories of both a chronic disease manifesting within one year from separation and continuity of symptomatology where applicable.  38 C.F.R. §§ 3.303, 3.307, 3.309.  The most probative evidence establishes the remote onset of any intraabdominal impairment.  IBS is not service-connected and there is no nexus to other service-connected disability.  38 C.F.R. § 3.310.  Although the Veteran served during the Persian Gulf War, there is no other disability due to undiagnosed illness and medically unexplained chronic multi symptom illnesses.  See 38 C.F.R. § 3.317.  The Board notes other factors.  There is no probative evidence to the contrary.  There is no doubt to resolve.  Therefore, service connection for adhesions is not warranted.

The Veteran remains in receipt of a 100 percent combined disability rating for compensation from May 2013, in addition to Special Monthly Compensation (SMC).

In denying the appeal, the Board notes that the claim for service connection for irritable bowel syndrome (IBS) is still under development from a prior BVA remand.  This decision reflects the rules of the Appeals Modernization Act (AMA) and closed evidentiary windows for the instant appeal.  If the Veteran would like VA to consider any new evidence that was not in the evidence currently of record the Veteran may file a Supplemental Claim (VA Form 20-0995) 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. 

Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record.  See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).

(Continued on the next page.)

 

In reaching this conclusion, the evidence persuasively stands against finding in favor of the claim in that it is not in "approximate balance" or "nearly equal" to the evidence that supports the claim.  See Lynch v. McDonough, No. 20-2067 (Fed. Cir. 2021) (holding "[E]vidence is not in 'approximate balance' or 'nearly equal,' and therefore the benefit-of-the-doubt rule does not apply, when the evidence persuasively favors one side or the other.")
 that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).

(Continued on the next page.)

 

In reaching this conclusion, the evidence persuasively stands against finding in favor of the claim in that it is not in "approximate balance" or "nearly equal" to the evidence that supports the claim.  See Lynch v. McDonough, No. 20-2067 (Fed. Cir. 2021) (holding "[E]vidence is not in 'approximate balance' or 'nearly equal,' and therefore the benefit-of-the-doubt rule does not apply, when the evidence persuasively favors one side or the other.")  Although the rule does not require that the evidence be in exact equipoise, there is still no doubt to resolve in the Veteran's favor.  38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).  Therefore, service connection for adhesions, as secondary to irritable bowel syndrome, is denied.

 

MICHAEL A. PAPPAS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	B. Bodi

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.