Citation Nr: 0601786 Decision Date: 01/20/06 Archive Date: 01/31/06 DOCKET NO. 00-22 491 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to Department of Veterans Affairs compensation pursuant to 38 U.S.C.A. § 1151 for stomach and intestinal problems. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. L. Wright, Counsel INTRODUCTION The veteran had active service from March 1962 to December 1964. This appeal comes before the Board of Veterans' Appeals (Board) from a June 1999 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. In this decision, the RO denied the veteran's claim for entitlement to VA compensation under the provisions of 38 U.S.C.A. § 1151 for stomach and intestinal disorders. As an additional matter, the Board notes that the veteran also submitted a timely Notice of Disagreement to a June 1998 rating decision which denied his claim of entitlement to nonservice-connected pension benefits. However, nonservice- connected pension benefits were subsequently granted by a December 1999 rating decision. In view of the foregoing, this issue has been resolved and is not on appeal before the Board. See generally Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997); Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). The veteran provided testimony at a hearing before a Veterans Law Judge (VLJ) from the Board in October 2003. The VLJ that conducted this hearing will make the final determination in this case. See 38 U.S.C.A. §§ 7102(a), 7107(c) (West 2002). This case was remanded by the Board in May 2001 and June 2004 for development of the evidence. It has now returned for appellate consideration. FINDINGS OF FACT Any additional disability the veteran had following hospitalization and treatment at a VA facility regarding his gastrointestinal disorders did not result from carelessness, negligence, lack of proper skill, error in judgment, or some other incident or fault on the part of the VA, nor as the result of an event that was not reasonably foreseeable. CONCLUSION OF LAW The requirements for compensation benefits pursuant to the provisions of 38 U.S.C.A. § 1151 for stomach and intestinal problems as a result of VA treatment have not been met. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. § 3.358 (2005). REASONS AND BASES FOR FINDINGS AND CONCLUSION VCAA The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) introduced several fundamental changes into the VA adjudication process. It eliminated the requirement under the old 38 U.S.C.A. § 5107(a) (West 1991) that a claimant must present a well- grounded claim before the duty to assist is invoked. A VCAA notice letter consistent with 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request or tell the claimant to provide any evidence in the claimant's possession that pertains to the claim. VA satisfied this duty by means of a letters to the appellant issued in August 2001, August 2004, and January 2005. By means of these letters, the appellant was told of the requirements to establish entitlement to VA compensation under the provisions of 38 U.S.C.A. § 1151 for his gastrointestinal disorders. He was advised of his and VA's respective duties and asked to submit information and/or evidence pertaining to the claim to the RO. A Statement of the Case (SOC) issued in February 2000 and Supplemental Statements of the Case (SSOC) issued in September 2001, June 2003, and June 2005 informed him of the applicable law and regulations, the evidence reviewed in connection with his claim by VA, and the reasons and bases for VA's decision. The RO initially denied this claim by rating decision of June 1999. The VCAA notification of August 2001, and thereafter, was issued after to this initial adverse decision. However, Board remands in May 2001 and June 2004 instructed the agency of original jurisdiction (AOJ) to issue the appropriate VCAA notice and readjudicate this claim after such notice had been issued. The AOJ completed these actions, thus the procedural defect has been cured. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). The U. S. Court of Appeals for Veterans Claims (Court) held in Mayfield v. Nicholson, 19 Vet. App. 103 (2005), that all sections of VA's notice letter should be construed in connection with each other to determine whether the document, read as a whole, addresses all aspects of the requisite notice under the provisions of the VCAA and the notice letter must be read in the context of prior relatively contemporaneous communications to the appellant from the AOJ. In addition, a complying notice need not necessarily use the exact language of the controlling statute or regulation specifying VA's notice obligations, so long as that notice properly conveys to a claimant the essence of the regulation. Id. at 124-28. Based on a review of the notification provided the appellant in this case and the above analysis, the Board finds that VA notification was in substantial compliance with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(l) as these documents, read as a whole, fulfilled the essential purposes of the VCAA. Id. at 130. VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claims for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d). The Board acknowledges that the veteran's claims file was apparently lost by VA sometime in the mid-1990s. Thus, his service records are missing. See Hayre v. West, 188 F.3d 1327, 1332 (Fed. Cir. 1999) (VA has a heightened duty to assist a veteran when his service medical records are missing through no fault of his own.) However, as this claim is related to VA treatment beginning in the early to mid-1990s, any information contained in the service records or post-service medical records preceding 1990 would not be pertinent to this claim, which is based on the provisions of 38 U.S.C.A. § 1151 allowing compensation for disabilities incurred as a result of VA medical treatment. The veteran has identified private and VA treatment, beginning in 1991, as pertinent to his claim. These records have been obtained and associated with the veteran's claims file. The veteran has not identified any other pertinent medical evidence. Therefore, the Board finds that further development of the treatment records is not warranted. Assistance shall also include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The veteran was afforded VA compensation examinations in March 1998, March through May 2003, and January 2005. These examinations noted the veteran's medical history, findings on examination, and the appropriate diagnoses and opinions. The examiners of March/May 2003 and January 2005 clearly noted in their reports that the veteran's claims file had been reviewed in connection with these examinations. Therefore, these examinations are adequate for VA purposes. See Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003), Charles v. Principi, 16 Vet. App. 370 (2002). The veteran provided testimony and argument at hearings before the RO in April and November 1999, and before the Board in October 2003. Transcripts of these hearings have been associated with the claims file. Based on the above analysis, the Board concludes that all pertinent evidence (reasonably obtainable) regarding the issue decided below has been obtained and incorporated into the claims file. As noted above, the Board previously remanded this case in May 2001 and June 2004 for development of the evidence. The May 2001 remand instructed the AOJ to request the veteran identify pertinent medical evidence, obtain identified medical evidence, provide VCAA notification, and obtain a VA examination and opinion. The VCAA notification and request to identify records was issued in August 2001, identified records were obtained in January 2003, and the requested VA examination and opinions were obtained in March/May 2003. In June 2004, the Board instructed the AOJ to obtain VA treatment records dated from the early 1990s and obtain a VA medical examination/opinion. The VA treatment records were obtained and associated with the claims file. The appropriate VA examination was conducted in January 2005. Based on these facts, the Board finds that the AOJ has fully complied with its remand instructions and those instructions do not provide any basis for further development. See Stegall v. West, 11 Vet. App. 268, 270-71 (1998). To the extent that VA in anyway has failed to fulfill any duty to notify and assist the appellant, the Board finds that error to be harmless. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2001) (The "harmless error doctrine" is applicable when evaluating VA's compliance with the VCAA). Of course, an error is not harmless when it "reasonably affected the outcome of the case." ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998); see also Mayfield, supra. As all pertinent evidence obtainable by VA has been associated with the claims file, the Board finds that the duty to assist has been fulfilled and any error in the duty to notify would in no way change the outcome of the below decision. The notification provided to the appellant in the letters, SOC, SSOCs, and Board remands discussed above provided sufficient information for a reasonable person to understand what information and evidence was needed to substantiate the claim on appeal. In this regard, while perfection is an aspiration, the failure to achieve it in the administrative process, as elsewhere in life, does not, absent injury, require a repeat performance. Miles v. M/V Mississippi Queen, 753 F.2d 1349, 1352 (5th Cir. 1985). Based on the above analysis, the Board determines that no reasonable possibility exists that further assistance would aid in the substantiation of the appellant's claim. 38 U.S.C.A. § 5103A. In addition, as the appellant has been provided with the opportunity to present evidence and arguments on his behalf and availed himself of those opportunities, appellate review is appropriate at this time. See Bernard v. Brown, 4 Vet. App. 384 (1993). Compensation under 38 U.S.C.A. § 1151 The veteran has contended that he developed gastrointestinal (GI) bleeding in 1991 as a result of ibuprofen/nonsteroidal anti-inflammatory drugs (NSAIDS) that were prescribed by VA in the early 1990s for carpal tunnel syndrome. Further, he maintains that he has current stomach and intestine problems are a result of being prescribed this medication. At his April and November 1999 personal hearings he testified that he had no stomach problems prior to being prescribed ibuprofen. He testified that he was prescribed too high of a dose of ibuprofen by VA. The veteran argued that his VA healthcare providers should have detected the gastrointestinal problems caused by his ibuprofen use in the early 1990s prior to this medication resulting in his current severe gastrointestinal diseases. At his Board hearing in October 2003, the veteran claimed that his VA physicians had prescribed the use of 800 milligram (mg.) tablets of ibuprofen, apparently in 1995, for the treatment of his carpal tunnel syndrome. Prior to 1995, he described his stomach problems as having "acid" once in a while. He appears to testify that his GI bleeding started soon after the use of ibuprofen and resulted in the development of severe gastrointestinal diseases diagnosed in 1997. The veteran claimed that his VA physicians took him off ibuprofen "right away" after his gastrointestinal problems developed. He claimed that a VA physician had informed him that his use of ibuprofen has caused holes in his stomach which had resulted in severe GI bleeding. The record reflects that the veteran filed his 38 U.S.C.A. § 1151 claim in November 1998. Effective October 1, 1997, 38 U.S.C.A. § 1151 was amended by Public Law 104-204 to require a showing not only that the VA treatment in question resulted in additional disability but also that the proximate cause of the disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the medical or surgical treatment, or that the proximate cause of additional disability was an event which was not reasonably foreseeable. Private medical records show that the veteran was hospitalized in April 1991. A report of history and physical noted that the veteran initially denied any prior GI problems, but subsequently admitted to being seen at the VA hospital in the early 1980' s because of symptoms of gastroesophageal reflux. No formal evaluation was undertaken, and he was advised to sleep with two pillows. Further, the veteran reported that he had had intermittent retroxiphoid discomfort described as heartburn on occasion for many years, especially after the use of spicy foods for which Alka-Seltzer was used several times yearly (date of last use was unclear). He also reported that he had been using proprietary ibuprofen either as generic medication or Advil for right wrist pain on occasion for a number of years, and last used such medication in early March 1991. Impressions based upon this history and examination of the veteran included probable iron deficiency, doubtful malabsorption, likely due to GI blood loss (doubtful genitourinary loss). Moreover, it was stated that the sources of the GI loss were possibly related to proximal gut loss due to peptic disease and proximal gut (history of NSAID use and occasional use of Alka-Seltzer for many years with gastroesophageal reflux by history), varices related to underlying liver disease, less likely due to arteriovenous malformation or neoplasm. To was also noted to rule out distal gut blood loss secondary to neoplasm. The final diagnoses on the discharge summary were iron deficiency anemia; alcoholic liver disease with probable cirrhosis; portal hypertension; esophageal varices with probable intermittent bleeding; ascites; colon polyps; diverticulosis; chronic alcoholism; and fever (etiology unclear) that resolved on observation. It was found to be doubtful that the fever was related to alcoholic hepatitis. A VA discharge summary for a period of hospitalization in July to August 1996 noted a history of "GI bleed, secondary to Ibuprofen." The veteran was also noted to have a history of alcoholic liver cirrhosis and developed "slight" alcohol withdrawal symptoms during the hospitalization. The diagnoses were gastritis with upper gastrointestinal bleed, pancytopenia, increased liver function tests secondary to alcohol, and mild alcohol withdrawal. Various VA medical records are on file which covers the period from November 1996 to January 2000. These records include hospitalization reports, examination reports, and outpatient records which show that the veteran was treated on various occasions for stomach and intestine problems. The veteran underwent a period of VA hospitalization from October to November 1997 because of GI bleeds. Procedures performed during this hospitalization included exploratory laparotomy, gastrostomy, splenectomy, repair of hiatal hernia, and Nissen fundoplication. The veteran was afforded a VA compensation examination in March 1998. The examiner noted that he did not have the veteran's claims folder or treatment records for review. The veteran reported a history of GI bleeding beginning in 1991 and subsequent hospitalizations and surgeries for this problem. He acknowledged that he had been a heavy drinker, but had stopped the use of alcohol in October 1997. He also noted that he quit smoking tobacco products several years ago. However, he reported his continued use of a "lot of coffee." After an examination of the veteran, the diagnosis was fatigue and weakness as a residual of surgery for extensive GI bleed. The examiner further commented that with no medical records available, he could not provide information on the details of the veteran's medical history and this situation made it very difficult for the examiner to evaluate the veteran's gastrointestinal problems. In March 1999, the veteran underwent a VA gastrointestinal examination. The examiner noted that the veteran's VA file was available and reviewed in addition to his electronic chart. The veteran reported that his problems began in 1991, when he was given ibuprofen for carpal tunnel syndrome. Shortly thereafter, he was hospitalized with a GI bleed that he asserted was secondary to NSAIDS. He also described his various stomach and intestine problems since that time, including his various periods of hospitalization. Following examination of the veteran, the examiner diagnosed, in part, GI bleeding, and noted that the veteran had a many year history of multiple GI bleeding related probably to NSAID use initially, as well as to chronic alcohol abuse. It was also noted that the veteran had a history of gastritis, gastric ulcer, Barrett's esophagus without dysplasia, as well as colonic diverticula and colon polyps. The examiner further commented that the veteran was now status-post bleed 1997, requiring massive packed red blood cell transfusion. It was also noted that the veteran underwent laparotomy with gastrostomy, splenectomy, and Nissen fundoplication for hiatal hernia. The veteran seemed to be doing well, without significant abdominal pain. Additional diagnoses included history of alcohol-related liver disease, incisional hernia, and anemia. In January 2000, the veteran underwent surgery at the VA due to Barrett's esophagitis with severe dysplasia. This surgery was performed by a Dr. C.D. In an April 2000 statement, Dr. C.D. noted the procedures the veteran underwent during his October to November 1997 VA hospitalization, and stated that the veteran, at that time, was taking large amounts of NSAIDS. Further, Dr. C.D. stated that these drugs likely accounted for the veteran's GI hemorrhage. In a May 2000 report, Dr. C.D. stated that he first came into contact with the veteran approximately three to five years earlier, when the veteran complained of GI bleeding. In October 1997, Dr. C.D., having not been able to determine the cause of the veteran's bleeding, performed a splenectomy and a fundoplication, during which he observed that the veteran appeared to have an alcohol problem because of the condition of the liver. It was noted that the veteran never mentioned he was taking any NSAIDS when he first met Dr. C.D. Further, during the October 1997 surgery, Dr. C.D. also discovered that the veteran had a condition known as hypertension in the esophagus, which could be caused by alcohol abuse. Additionally, it was determined that the veteran had some pre-cancerous cells, or dysplasia, in the esophagus, which was a condition known as Barrett's syndrome. It was noted that Dr. C.D. performed surgery in January 2000 because of the Barrett's syndrome by removing part of the veteran's esophagus and replacing it with part of the intestine. Dr. C.D. noted that the veteran complained about various doctors prescribing Motrin (an NSAID), which the veteran felt caused his GI bleeding. The veteran never identified the doctors to Dr. C.D., and Dr. C.D. never prescribed NSAIDS to the veteran. Moreover, Dr. C.D. stated that he could not find anything in the veteran's medical file showing that VA physicians had prescribed NSAIDS. Dr. C.D. stated that the second sentence, which referenced the veteran's use of large amounts of NSAIDS, was based on the veteran's self-reporting and not on any medical fact or opinion by Dr. C.D. A VA physician provided a medical opinion regarding the veteran's claim for VA compensation in March and April 2003. She indicated that she had reviewed the medical evidence in the veteran's claims file and in his VA treatment records. She noted that the veteran had a complicated history. He had multiple surgeries because of GI bleeding and reflux that led to Barrett's esophagus. He also had suffered with several incisional hernias due to these surgeries. The only notation in the medical evidence to prescribed NSAIDs was in April/May 1990 when the veteran was prescribed Motrin for carpal tunnel syndrome, and in November 1994 for the treatment of a wrist injury. The Motrin taken in April/May 1990 was indicated in the records to be effective and its use was continued, but the records failed to indicate for how long. The VA reviewer found that this use of Motrin was "certainly appropriate, and a reasonable doses was prescribed." The physician indicated that in November 1994, the use of NSAIDs was for a short course. The reviewer noted that hospitalization records in March and April 1991 noted that the veteran had a history of intermittent use of ibuprofen and Advil for right wrist pain, but "it is not known if this was prescribed by an MD at that time, or if it was over the counter." These records also noted a history of reflux and chronic consumption of alcohol (6 to 12 beers a day). The treating physicians in March/April 1991 attributed the GI bleed to "portal hypertension with possible contributions by the use of nonsteroidals, Alka Seltzer (with Aspirin) and regular alcohol use." In March 2003, the VA reviewer commented: For all the GI bleed episodes mentioned and documented in the records above, the etiology was thought to be secondary to portal hypertension. There were no ulcers identified or pathology typical of NSAID related injury. The GERD disease that led to the development of Barrett's epithelium and dysplasia was not related to NSAID use. The patient had a well- documented history of alcohol use and prior smoking history. He quit cigarettes 27 years ago and quit alcohol in 1997. The records provided do not document nonsteroidal medication prior to 1990, and do not give any indication for NSAIDS. I am unable to make any comment about NSAID use or the appropriateness of such use based on the current records. The VA physician was provided with the full VA claims folder for review in April 2003. After reviewing these records, she provided the following comments: It appears that [the veteran] was prescribed Ibuprofen for his carpal tunnel syndrome in 1990. The indication and amount prescribed were appropriate, and at that time there was no history of GI bleed. The need for his surgery was esophagitis with Barrett's epithelium. This is not related to his ibuprofen use. I cannot document how long ibuprofen was prescribed, but have no record of this being prescribed after the onset of his GI bleed. I find no evidence for negligence or lack of good judgment in the man regarding the prescription of ibuprofen in 1990. I cannot blame the ibuprofen for the anemia observed in 3/90. It was probably multifactorial, with portal hypertension and GERD being significant factors. The role of ibuprofen is speculative in regard to his GI bleeds and to any other gastric surgery. The other surgeries are not thought to be related or in any way precipitated by nonsteroidal use. In January 2005, the veteran was afforded a VA compensation examination. This examiner indicated that he had reviewed the veteran's claims file and electronic treatment records in connection with an examination of the veteran. It was noted that the veteran was unable to give a detailed history of his past surgical procedures and events. Most of the history was obtained after reviewing all the volumes of his chart and all records on computer database as well as written records that were available to the examiner. It was determined that the veteran had a prolonged and complicated medical/surgical history. At the present time, the veteran had occasional stomach pains after eating. This usually resulted in an abdominal cramping sensation after eating. He did not take medication for this. He stated that it occasionally caused nausea as well, maybe less than one time per week; he did not have vomiting. He also had a burning sensation in his midsternal and upper throat area that occurred about two times per week and was worse when lying down. For this he took Pepto-Bismol, which he averaged one capful about twice a week. He denied any dysphagia or odynophagia. He did have erratic bowel movements, and they were not regular, on average maybe one bowel movement every day or every two days. Occasionally he had loose stools as well, which were chronic since his surgery in 1997. He believed his weight had been relatively stable and had not changed. He had a protuberant abdominal habitus, which he stated had also been unchanged. He could not recall exactly what medications he had been taking. He had not altered his eating habits except that he can no longer eat steak because he stated it was hard to go down. Also he had to eat small bits of food at a time. He had not had any further upper GI bleeding in the last few years since he quit alcohol, which was approximately in 1997, when he had his major surgery. His other habits included tobacco, which he quit 30 years ago. At that time, he smoked 3/4 a pack of cigarettes a day. He stated he started drinking alcohol when he was 14 years old and quit approximately eight years ago, when his gastrointestinal problems started in approximately 1996-97. He stated he drank half a case a day or 12 beers a day. He denied any illicit drug use. Regarding the veteran's Barrett's esophagus, it was noted by the examiner that the veteran had a long history of heavy alcohol use. It was determined that he had multiple upper gastrointestinal bleeding that began approximately 1991, or at least documentation of this problem beginning in 1991. There was also mention of gastritis as well as ulcer disease, although the exact dates are not documented. Additionally, the veteran had endoscopies that have shown gastric varices as well as signs of portal hypertension. The veteran had multiple endoscopies. In November 1996, he had biopsies taken of a section of his esophagus that identified Barrett's esophagus. At that time, his pathology did not reveal any dysplasia. Subsequently, veteran had an upper GI bleed in October 1997 with another endoscopy. At that time, he had active bleeding, and his endoscopy was to identify a source of bleeding. The endoscopy in September 1999 had biopsies that showed some areas of high-grade dysplasia. Because of the high-grade dysplasia of his Barrett's esophagus, an esophagectomy was indicated to remove this area of Barrett's esophagus. He subsequently had an esophagectomy and proximal gastrectomy with colonic interposition in January 2000. The examiner found this a direct result of the high-grade dysplasia diagnosed on the biopsies from September 1999. Regarding the issue of hernias and staph infection, the veteran was again noted to have a long history of upper GI bleeding, alcohol abuse, as well as gastroesophageal reflux disease. He was treated in October 1997 with exploratory laparotomy, gastrostomy, splenectomy, and repair of hiatal hernia as well as Nissen fundoplication. This was during an episode of admission when he presented with upper GI bleeding. It was after this November 1997 hospitalization where he had his exploratory laparotomy, gastrostomy, splenectomy and repair of hiatal hernia as well as Nissen fundoplication that he had occurrence of a ventral hernia. Also of note, the surgical report in October 1997 stated that he had ascites and a cirrhotic liver. Review of the inpatient notes dated in October and November 1997 revealed that he did have a coagulase-negative staphylococcus bacteremia with positive blood cultures that was treated with appropriate antibiotics. He was discharged to a nursing home, and then he was subsequently readmitted in November 1997 with a diagnosis of abdominal wall cellulitis or infection of his abdominal incision. This was also treated with antibiotics, and then the veteran was discharged. Concerning the veteran's ventral hernias, it was since his October 1997 surgeries that he had recurrent ventral hernias. Review of notes shows that he had multiple repairs: in November 1998, in June 2000, and then in October 2003 he had his ventral hernia repaired with a mesh. Since that time he continued to have a recurrent ventral hernia which he stated had not really bothered him, except at times he noticed it when the hernia pouches out. This was in his mid-abdominal section. He did not have any chronic pain or distension from his hernia. Additionally, he had not had the hernia persist where it could not be easily reduced. Also of note, his June 2000 hernia repair was termed as "elective repair," as patient had subjective symptoms of the hernia and desired to have it repaired. Other procedures also were in March 2000 when the veteran had another endoscopy with dilatation for dysphagia. The examiner also noted that veteran was hospitalized for a small bowel obstruction in July 2000. Based on examination of the veteran, the impressions included Barrett's esophagus, incisional hernias, staphylococcal infection, abdominal wall infection/cellulitis, and a small bowel obstruction. Based on a review of the medical evidence, the examiner provided the following opinions. Regarding the Barrett's esophagus, there was no evidence or data to support that he was not treated appropriately. It was the examiner's opinion that the veteran's Barrett's esophagus was diagnosed, identified, monitored, and properly treated. The examiner commented: Barrett's esophagus can arise from long- standing gastroesophageal reflux disease [GERD]. It is likely that his prior alcohol use and smoking use have contributed to his esophageal reflux disease. Endoscopy is used to monitor Barrett's esophagus. Once a person has Barrett's esophagus the concern is for transition into cancer, thus requiring monitoring. This veteran was identified as having high-grade dysplasia, which is a precancerous lesion, and thus esophagectomy was indicated, which was done. Thus, in summary, his identification of Barrett's as well as monitoring and treatment with esophagectomy appear to be properly identified and treated. Regarding the incisional hernias, the veteran had extensive and major surgery after upper GI bleeding in October 1997, requiring a large abdominal incision. He subsequently had at least three separate episodes of ventral hernia repair. This veteran currently had a protuberant abdomen, which he stated he had in the past. The reviewer noted that obesity or an obese abdomen can increase the risk for a hernia. After review of prior records and interview with the veteran, the examiner concluded that there was no evidence that VA was at fault in causing his ventral hernias. The examiner commented: Ventral hernias can certainly occur after a major abdominal surgery. This likely represents complication from his surgery and does not indicate fault by the VA. Additionally, ventral hernias can recur and require subsequent repair. Based on this review, there is no evidence that the VA was at fault concerning his ventral hernias. Regarding the staphylococcal infections, the veteran was documented to have a staphylococcus coagulase-negative bacteremia during and postoperatively from his hospitalization in October 1997. The reviewer found that this infection had been appropriately treated with antibiotics. Sterile and usual surgical technique and precautions were maintained throughout all his procedures, by documentation. The examiner commented: Infection is a listed complication of any type of surgery, abdominal surgery included. Thus after review of notes, there is no evidence to suggest fault of the VA. Thus his course of treatment postoperatively and also use of antibiotics when infection was diagnosed are within reasonable medical care and no evidence of faulty care. Concerning the veteran's abdominal wound infection/cellulitis, the reviewer indicated that again this was a complication that could occur after surgery. There was no evidence after review to indicate any other fault by the VA. On the issue of a small bowel obstruction, the examiner noted that after abdominal surgery there is an increased risk of small bowel obstruction, and this again is not a fault, but actually a complication that can occur after any abdominal surgery. The reviewer found that the veteran appeared to have been appropriately treated during that particular hospitalization. The January 2005 examiner summarized his findings as: ...this veteran has an extensive alcohol- use and tobacco history and gastroesophageal reflux disease history. Additionally, he did use NSAIDs for a period of time for his carpal tunnel syndrome, which had been addressed earlier in a 2003 C&P exam case. His Barrett's esophagus appears to be diagnosed appropriately and properly managed without evidence of fault, according to my review of records. Additionally, his incisional hernias are likely a direct result of his operation [in October 1997], and are considered a complication, but there is no evidence to suggest fault on the provider's or VA's behalf in that hernias can occur after major abdominal surgery. This also is true for his staphylococcal infection that occurred during that hospitalization or subsequent cellulitis hospitalization. No evidence of fault or inappropriate treatment could be identified after review of records as pertaining to this [case]. For purposes of VA compensation under 38 U.S.C.A. § 1151, a disability is a qualifying additional disability, if the additional disability was not the result of the veteran's willful misconduct and the disability was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by the Secretary of VA, and the proximate cause of the disability or death was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or an event not reasonably foreseeable. In the current case, the Board concedes that the veteran was receiving VA medical treatment for his carpal tunnel syndrome, for which he was prescribed 400 mg of ibuprofen in 1990, and a separate prescription of ibuprofen in 1994. In order to receive compensation under 38 U.S.C.A. § 1151 due to VA treatment, the evidence must establish that the veteran sustained additional disability and that this additional disability is etiologically linked to the VA treatment by the appropriate standard under 38 U.S.C.A. § 1151. If there is no competent evidence of additional disability or no evidence of a nexus between the hospitalization, medical or surgical treatment, or examination and the additional disability or death of the veteran; the claim for compensation under 38 U.S.C.A. § 1151 must be denied. Even if there is VA hospitalization, medical or surgical treatment, or examination, competent evidence of additional disability or death of the veteran, and evidence of a nexus between the treatment at issue and the additional disability or death; the grant of benefits under § 1151 still requires evidence showing that the additional disability was not the "continuance or natural progress" of the disease or injury for which treatment was provided; "coincident with" treatment provided; a "necessary consequence" of (i.e., certain or intended to result from) properly administered, consensual treatment provided; or, the result of the veteran's "willful misconduct" or "failure to follow instructions" (except as to incompetent veterans). 38 C.F.R. § 3.358(b), (c). If any of the above elements is applicable, the claim must be denied. The veteran has presented lay evidence that his VA healthcare providers prescribed the regular use of 800 mg of ibuprofen beginning in 1991. He also claims that the use of this medication caused his gastrointestinal disabilities, to include GI bleeding. As a lay person, the veteran is competent to provide evidence of injuries/events and symptomatology. However, he is not competent to provide medical opinions regarding etiology of his disabilities and symptoms, when such symptoms are the result of a disease that is not easily discernable by lay observation (such as GI bleeding and disorders of the gastrointestinal tract). See Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). The record reveals that the veteran was treated by VA from at least 1990 and prescribed ibuprofen at that time for his wrist pain. However, the noted prescribed amount was 400 mg. There is no indication in the record, or in the review conducted by VA physicians in March/April 2003 and January 2005, that this prescription was of indefinite duration. The examiner of March/April 2003 noted that the contemporaneous records only reported two episodes, in 1990 and 1994, during brief periods when NSAID had been prescribed by VA healthcare providers. This finding is supported by the history taken from the veteran during his hospitalization in April 1991. See Madden v. Gober, 125 F.3d 1477, 1480-81 (Fed. Cir. 1997) (An appellant's claims can be contradicted by his contemporaneous medical history/complaints.) At that time, he reported that he had used NSAID for wrist pain "on occasion for a number of years." This notation appears to support the finding that the veteran's use of NSAID was not under the supervision of his treating physicians, but instead was self-prescribed/self-administered. In addition, this history noted that the veteran's gastrointestinal reflux symptoms had existed for many years prior to 1991. The VA reviewers in March/April 2003 and January 2005 have attributed his severe GI bleeding and severe gastrointestinal disorders to his GERD, which in turn resulted from his chronic use of alcohol and tobacco products. The veteran's surgeon (Dr. C.D.) provided an opinion in April 2000 that did attribute the veteran's gastrointestinal bleeding and disorders to the use of NSAID. However, this physician acknowledged that this opinion was based on a subjective history provided by the veteran and that there was no indication in the treatment records that the use of NSAID had been prescribed. As this opinion is based on a subjective history not supported by the contemporaneous medical evidence, Dr. C.D.'s opinion carries little probative weight. See Godfrey v. Brown, 8 Vet. App. 113, 121 (1995) (VA adjudicators are not required to accept a physician's opinion that is based on a claimant's recitation of medical history.) The veteran has also claimed that his VA treating physicians had verbally informed him that his use of NSAID had led to his severe GI bleeding. There is no notation in the treatment records reflecting this opinion. See Robinette v. Brown, 8 Vet. App. 69, 77 (1995) (A claimant's account of what a physician purportedly said, filtered as it is through a lay person's sensibilities, is not competent medical evidence.) This type of lay evidence, unsupported by the contemporaneous medical evidence, does not establish the required nexus under the provisions of 38 U.S.C.A. § 1151. Thus, the contemporaneous medical evidence does not support the allegation that VA practitioners prescribed or encouraged the veteran to take 800 mg doses of ibuprofen on a regular basis from 1990 to 1997. The contemporaneous records are also clear that until 1997, the veteran had significant intake of alcohol and coffee that was attributed to his subsequent gastrointestinal problems, to include his GI bleeding. While the veteran is competent to report symptoms of his gastrointestinal disorders, to include the type and frequency of medication used to treat these disorders, the Board finds that his lay evidence on these subjects lacks credibility. See Washington v. Nicholson, slip op. 03-1828 (U.S. Vet. App. Nov. 2, 2005). As noted above, the contemporaneous evidence does not support his claims that his VA healthcare providers prescribed continuous or frequent use of NSAID from 1990. The history reported by the veteran himself in 1991 noted the use for many years of NSAID; that is, he appears to acknowledge use of NSAID prior to his treatment by VA beginning in 1990. The contemporaneous VA treatment records only reported ibuprofen prescribed for brief periods in 1990 and 1994. In addition, the dosage prescribed by these healthcare givers appears to be half that described by the veteran; that is, 400 mg versus the 800 mg alleged by the veteran. Based on the contemporaneous evidence, his claims of VA practitioners prescribing large doses of ibuprofen is not credible. The veteran's statements reflect the argument that VA should have diagnosed his severe gastrointestinal disorders earlier than 1997, and the delay allowed these disorders to permanently deteriorate. As a lay person, the veteran is not competent to provide an opinion on the propriety of the treatment provided by his healthcare professionals. After a complete and comprehensive review by two competent physicians in March/April 2003 and January 2005, it was determined in both reviews that VA's course of treatment was not negligent or that the actions of the VA healthcare providers led to additional disability associated with the gastrointestinal system. The reviewers' detailed reasons and bases for these opinions are reported in the above factual background. These opinions are based on a thorough review of the subjective/medical history and contemporaneous treatment records; and have provided a detailed and thorough analysis of the etiology of the veteran's gastrointestinal disorders and their subsequent treatment by VA. These opinions are complete and comprehensive and, therefore, are accepted by the undersigned. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The veteran has not provided any competent evidence that the course of treatment provided by VA violated any accepted practices of the medical profession. While the veteran's gastrointestinal disorders do appear to have become worse over the course of the 1990s and 2000s, there is no competent evidence that additional disability was proximately caused by the carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of his VA healthcare providers. The reviewer of January 2005 clearly indicated that the complications from the surgery provided by VA (to include incisional hernias, staphylococcal infections, wound infections/cellulitis, and small bowel obstruction) were recognized complications that could occur after the surgeries performed on the veteran. Thus, these events were reasonably foreseeable and noted as possible complications from the surgery/treatment of the veteran's severe gastrointestinal disorders. Both the March/April 2003 and January 2005 reviewers found the treatment and care provided by VA was appropriate and that any additional disability or complication sustained by the veteran from the necessary treatment was a foreseeable consequence of these procedures. In conclusion, the evidence establishes that the veteran has residuals of severe gastrointestinal disorders; however, a preponderance of the evidence is against the claim for disability benefits under the provisions of 38 U.S.C.A. § 1151 for VA treatment of these disorders. There is no competent evidence that the treatment VA provided involved any element of fault or that any complication was not a reasonably foreseeable event of the necessary and appropriate treatment. The only evidence submitted by the veteran to establish his claim is his own bald allegations, which is not competent or credible evidence. The opinion of Dr. C.D. provides little probative evidence as this opinion was based on the veteran's subjective history and, in fact, failed to attribute the use of NSAID or cause of his gastrointestinal disorders to any VA treatment. The Board finds that the medical opinions provided in March/April 2003 and January 2005, prepared by competent professionals, skilled in the evaluation of disabilities, are more probative of the degree of impairment, diagnosis, and etiology of a disability, than the lay statements. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (Holding that interest in the outcome of a proceeding may affect the credibility of testimony.) To this extent, the preponderance of the evidence is against the current claim and the doctrine of reasonable doubt is not for application. See 38 U.S.C.A. § 5107(b), Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Finally, the Board notes that in cases where a veteran's service records are missing through no fault of his or her own; VA has a heightened duty to explain its findings and conclusions. See Hayre, supra. The Board believes that the above discussion has met this duty. (Continued on next page.) ORDER Entitlement to VA compensation benefits under 38 U.S.C.A. § 1151 for stomach and intestinal problems is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs