Citation Nr: 0902694 Decision Date: 01/27/09 Archive Date: 02/09/09 DOCKET NO. 05-01 859 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to the service- connected conditions of chronic obstructive pulmonary disease ("COPD") and cervical disc protrusion at C3 and C4 ("back disability"). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. Finn, Associate Counsel INTRODUCTION The veteran served on active duty from July 1977 to July 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) St. Louis, Missouri. The veteran perfected a timely appeal of the rating action to the Board. In March 2008, the veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A copy of this hearing transcript has been associated with the claims file. The issue of entitlement to an increased rating in excess of 10 percent for service-connected postoperative cervical spine, to include radiculopathy of the shoulders has been withdrawn and is no longer on appeal. (See October 2007 written statement). FINDING OF FACT The competent medical evidence of record shows that the medications the veteran took for his service-connected back disability and COPD aggravated his GERD. CONCLUSION OF LAW The veteran's GERD is proximately due to his service- connected back disability and COPD. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A (West 2002); 38 C.F.R §§ 3.159, 3.303, 3.310(a) (2008). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). In this case, the Board is granting in full the benefits sought on appeal. Any defect, if one exists, with respect to either the duty to notify or the duty to assist must be considered harmless and will not be discussed. II. Service Connection for GERD Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for certain chronic diseases when it is manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309. Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury; or, for any increase in severity of a non-service-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 progression of the non-service-connected disease. 38 C.F.R. § 3.310 (2005); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). In order to establish service connection for the claimed disorder, there must be (1) a current disability; (2) medical or, in certain circumstances, lay evidence of the in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Here, the veteran claims that his GERD is secondary to medications taken for his service-connected COPD and C3-C4 disc protrusion with neural foraminal encroachment. His basic contention is that his claimed disorder was caused by the use of Prednisone. In an October 1997 rating decision, service connection was awarded for COPD and a June 1996 Supplemental Statement of the Case granted service connection for the back disability. Medical treatment records reflect that the veteran used Prednisone from 1996 to November 1999. (See Treatment record dated from May 1996 to September 1999). The veteran was also noted to be using Ranitidine during an August 2000 VA respiratory diseases examination. Recent VA medical records indicate treatment and medication for GERD. A January 2002 VA record reflects that GERD was among the diseases in the veteran's medical history. The section of the veteran's December 2004 VA spine examination report addressing his past medical history indicates that he had to take Omeprazole "due to his chronic gastroesophageal; reflux problems with long-term therapy on nonsteroidals and [P]rednisone therapy." In April 2005, R.H., M.D., noted that he had treated the veteran since August 2003. The veteran was noted to have a history of peptic ulcer disease and gastritis and was currently being treated with 20 mg of Omeprazole daily. In regard to the risk factors for developing this disease process, the veteran's prior history of Prednisone use for many years was "at least partially a contributing factor." The veteran underwent a VA esophagus and hiatal hernia examination in June 2005. In the report of this examination, the examiner did not specify which records had been reviewed in conjunction with the examination; she did, however, note prior records, including a January 2003 MRI and an undated EMG report. During the examination, the veteran noted that he had not been on Prednisone since his discharge from service. The examiner rendered a diagnosis of erosive esophagitis secondary to reflux. She stressed that there was no evidence to suggest that this diagnosis "is secondary" to his steroid use, as he had not been on steroids since 1997. The veteran was noted to have a multitude of factors resulting in erosive esophagitis, including alcohol and smoking and "his narcotic as well as nonsteroidal use for pain control as well as his reflux." The VA examiner, however, did not address whether the veteran's steroid use aggravated his GERD. The Board also observes that, in February 2008, T.N., D.O., noted that Prednisone was well-documented to markedly sensitize and worsen GERD, gastritis, and duodenitis, all of which the veteran was noted to have. He also stated that the veteran had a current diagnosis of GERD and that it was at least likely as not that the Prednisone he took for his lung condition caused his current condition of GERD. The Board requested a VHA opinion in October 2008 for clarification of the etiology of the veteran's GERD. The VA examiner noted the veteran's history and medication use of oral, inhaled, and injected steroids, as well as anti- inflammatory agents for his COPD and disc problems. He stated that two of the medications have been associated with the development of esophagitis, gastritis, and peptic ulcer disease. He noted that the veteran had a prior endoscopy that documented the presence of gastritis and esophagitis; and, that this usually occurs temporally with recent or ongoing use of NSAIDs or oral steroids. With regard to the complications, the examiner stated that: [i]t is felt that steroids and NSAIDs do have a causal relationship and this association has been well-documented in many medical papers. However, with respect to chronic reflux, there is no data to suggest that steroids or NSAIDs cause chronic reflux or GERD. He further stated that: [W]hile steroids and NSAIDs may not have caused GERD, certainly these medications can exacerbate reflux symptoms. Furthermore, these medications can cause espophagitis, gastritis, and ulcers, complications [that] the veteran has been found to have on endoscopy. He concluded that a number of factors can worsen or aggravate reflux including steroids as well as smoking; and, that it was as least likely as not that steroids and/or NSAIDs aggravated his GERD. The veteran also submitted numerous studies linking gastritis to steroid use. (See Gastritis Causes, at http://www.emedicinehealth.com (last visited Feb. 23, 2008); Major Side Effects of Glucocorticoids, at http://uptodateonline.com (last visited Apr. 7, 2005); Prednisone The Drug We Love to Hate, at http://ibdcrohns. about.com (last visited at Feb. 2008 ); et. al. The Board notes that medical treatise evidence can, in some circumstances, constitute competent medical evidence. See Wallin v. West, 11 Vet. App. 509, 514 (1998); see also 38 C.F.R. § 3.159(a)(1) [competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses]. However, the Court has held that medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). In reviewing the above evidence, the Board notes that the evidence indicates a multifactorial etiology of GERD. In any event, the evidence clearly shows that the medication used for the veteran's COPD and back disability at least aggravated the veteran's GERD. What is less clear is the extent to which the medication played a causal role with GERD. Regardless, the Board is satisfied that the inquiries necessitated by 38 C.F.R. § 3.303(b) as to any "baseline" disability have thus been fully addressed, and any doubt in this instance should be resolved in the veteran's favor. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (when it is not possible to separate the effects of a nonservice- connected condition from those of a service-connected condition, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service- connected condition). While both VA examiners concluded that the medications taken for the service-connected low back disability and COPD did not cause the veteran's GERD, at least one VA examiner concluded that the medications taken for the service- connected back disability and COPD aggravated the GERD. When the aggravation of a non-service-connected disorder is proximately due to or the result of a service-connected disorder, service connection is warranted. Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board finds the statement of the VA examiner, combined with the private positive nexus opinions submitted by the veteran, to be sufficient medical evidence of a link between the medications and the veteran's claimed aggravation of his GERD. Overall, the preponderance of the evidence is in favor of the veteran's claim, as such service connection is warranted on a secondary basis. ORDER Entitlement to service connection for GERD, to include as secondary to the service-connected conditions of COPD and cervical disc back disability, is granted. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs