Citation Nr: 1230031 Decision Date: 08/30/12 Archive Date: 09/05/12 DOCKET NO. 09-24 688 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for a liver disability (claimed as fatty liver, liver cysts, liver tumor, hepatitis (enlarged liver), chronic fatigue, and joint pain). ATTORNEY FOR THE BOARD S. Becker, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Air Force from January 1982 to June 1992. He served in the United States Army Reserve prior thereto on various periods of active duty for training, to include from August to October 1981, and of inactive duty for training. This matter comes before the Board of Veterans' Appeals (Board) from a rating decision dated in January 2008 and March 2008 from the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. Service connection for a liver condition with enlarged liver, fatty liver, and liver tumor (also claimed as hepatitis); liver tumor condition; chronic fatigue condition; and joint pains conditions was denied in the former decision. Service connection was granted and an initial 50 percent disability evaluation was assigned for posttraumatic stress disorder (PTSD) in the latter decision. The Veteran appealed each of these determinations. In March 2011, this matter initially came before the Board. An initial evaluation of 70 percent for PTSD was assigned therein. The PTSD issue accordingly no longer is on appeal. The liver issue was recharacterized as indicated above for the sake of simplicity. It then was remanded for additional development. This development has been completed or at least substantially completed, as discussed below. Adjudication by the Board may proceed if otherwise in order. See Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Pertinent private treatment records dated in 2011 were submitted by the Veteran following the May 2012 supplemental statement of the case in which this matter last was adjudicated. He contemporaneously waived his right to have such evidence initially reviewed by the agency of original jurisdiction (AOJ), which in this case also is the RO. The Board thus has jurisdiction to consider it in the first instance here. See 38 C.F.R. § 20.1304(c). No other potential problems with adjudication on the merits are found. Accordingly, the following determination is based on review of the Veteran's claims file in addition to his Virtual VA "eFolder." FINDING OF FACT The preponderance of the evidence does not show that the Veteran's liver disability is in any manner related to his service. CONCLUSION OF LAW The criteria for establishing service connection for a liver disability are not met. 38 U.S.C.A. §§ 101, 1101, 1110, 1112, 1113, 1117, 1118, 1131, 1153, 1154, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.2, 3.102, 3.303, 3.307, 3.309, 3.317 (2011). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist Before addressing the merits of the issue of entitlement to service connection for a liver disability, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the AOJ of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability evaluation and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. The Veteran has not alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. The Veteran was notified via letter dated in May 2007 of the criteria for establishing direct and presumptive service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines disability evaluations and effective dates if service connection is awarded. This letter accordingly addressed all notice elements. It also predated the initial adjudication by the AOJ/RO in the aforementioned January 2008 rating decision. Nothing more was required. The March 2011 letter readdressing all notice elements and additional letters readdressing some of these elements therefore went above and beyond what was required. Pursuant to the duty to assist, VA is required to aid the claimant in the procurement of service treatment records and other pertinent treatment records, whether or not they are in Federal custody, as well as provide a medical examination and/or obtain a medical opinion when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Service treatment records, service personnel records, VA treatment records, and pertinent private treatment records regarding the Veteran have been obtained and associated with the claims file or "eFolder." The service treatment and personnel records were obtained by VA prior to the Board's March 2011 remand. The VA treatment records, which are from a particular facility and are not relevant (and thus not mentioned below), were obtained in compliance with this remand. The private treatment records were submitted by the Veteran on his own behalf. No such records were obtained by VA. The duty to assist is not applicable in this regard, however, as the Veteran has not identified any such records as being unsubmitted. See 38 U.S.C.A. § 5103A(b). A VA liver, gall bladder, and pancreas examination was afforded to the Veteran in March 2012, as directed by the Board's March 2011 remand. This remand further directed that this examination be conducted by a hepatologist or gastroenterologist "if at all possible." Yet the examiner who conducted it was the chief urology resident. Substantial compliance with the Board's remand nevertheless is found. A specialist, albeit not the specific specialist the Board had in mind, performed the examination. Further, the Board left open the possibility for this scenario as well as for the scenario of a general physician rather than a specialist performing the examination. Use of the phrase "if at all possible" indeed conveys acknowledgement by the Board that a hepatologist or gastroenterologist might not be able to perform the examination. The claims file and medical evidence located elsewhere (such as those in the "eFolder") were reviewed by the examiner, as indicated in both the March 2012 examination and an addendum thereto. This review encompassed all pertinent evidence with the possible exception of the 2011 private treatment records later submitted by the Veteran. It appears that this review also encompassed these records, most likely from the Veteran supplying them, as the examiner referenced findings of a liver biopsy discussed only in them. Even if this review did not encompass these records, a remand is not required for another examination to do so. The discussion below reveals that they are not so significant that there is more than a remote possibility the findings made or, more importantly, the opinion rendered as part of the examination would change with consideration of them. In addition to reviewing the claims file, the examiner additionally interviewed the Veteran about his relevant history and symptoms, performed a pertinent physical assessment, and undertook appropriate diagnostic testing. The examiner finally opined as to whether or not the Veteran has a liver disability as well as whether or not such a disability is related to a specific incident involving chemical exposure claimed by him to have occurred during service. All of this complied with the Board's March 2011 remand. Further, all questions necessary to render the determination made herein thus were answered. The examination accordingly is adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (defining adequacy with respect to medical examinations and opinions as those providing sufficient detail so that the Board can perform a fully informed evaluation). Significantly, the Veteran has not identified any particular additional development necessary for a fair adjudication of the claim that has not been undertaken. The record also does not indicate any such development. The Board thus finds that VA's duties to notify and to assist have been satisfied. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio, 16 Vet. App. at 183. Accordingly, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Service Connection The Veteran contends that he has a liver disability due to exposure to environmental hazards and carcinogens during his active duty service in Saudi Arabia or Bahrain during the Persian Gulf War. He alternatively contends that he has a liver disability due to exposure to a high level of monomethyl hydrazine, a carcinogenic fuel oxidizer for missiles, during his active duty service in April 1991. The Veteran indicates that he immediately experienced eye burning, chest tightness, difficulty breathing, vomiting, and twitching/shaking/uncontrollable muscle movements. He further indicates that he has experienced fatigue and worsening joint pain ever since. Finally, he indicates that he was diagnosed with fatty liver in April 1999, that he was diagnosed with hepatitis (enlarged liver) and liver cysts in 2004, and that one of these cysts was noted to be a possible liver tumor in 2007. Service connection "basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service . . . or if preexisting such service, was aggravated therein." 38 C.F.R. § 3.303(a); 38 U.S.C.A. §§ 1110, 1131. To establish direct service connection, there generally must be (1) medical or satisfactory lay evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical or satisfactory lay evidence of a nexus between the current disability and the in-service disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999); Barr, 21 Vet. App. at 303. Direct service connection also may be established if the evidence of record reveals chronicity or continuity. 38 C.F.R. § 3.303(b). If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. Id.; Barr, 21 Vet. App. at 303. Continuity of symptomatology post-service is required where a condition in service is noted but is not, in fact, chronic or where a diagnosis of chronicity legitimately may be questioned. Id.; Savage v. Gober, 10 Vet. App. 488 (1997). Further, direct service connection may be established for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for a disease is presumed to have been incurred in or aggravated by service even when there is no record of the disease during service if certain circumstances exist. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Applicable here are those for presumptive service connection for chronic diseases. 38 U.S.C.A. § 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). First, the Veteran must have served 90 days or more of active service during a period of war or after December 31, 1946. 38 U.S.C.A. § 1112(a); 38 C.F.R. § 3.307(a)(1). Second, the Veteran must have manifested a chronic disease such as cirrhosis of the liver to a compensable degree within one year from the date of separation from service. 38 U.S.C.A. § 1101(3), 1112(a)(1); 38 C.F.R. §§ 3.307(a)(2), (3), 3.309(a). Affirmative evidence rebutting in-service incurrence or aggravation of a chronic disease must be taken into consideration even if the aforementioned circumstances are met. 38 U.S.C.A. §§ 1113, 1153; 38 C.F.R. § 3.307(d). Special service connection rules exist for Persian Gulf Veterans. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. Like with presumptive service connection and unlike with direct service connection, there is no nexus requirement for these Veterans if certain circumstances exist. Gutierrez v. Principi, 19 Vet. App. 1 (2004). They rather simply must manifest objective indications of a qualifying chronic disability either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a compensable degree by December 31, 2016. 38 U.S.C.A. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1); 76 Fed. Reg. 81834 (Dec. 29, 2011). The Southwest Asia theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e)(2). Objective indications include fatigue and joint pain. 38 U.S.C.A. § 1117(g); 38 C.F.R. § 3.317(b). A qualifying chronic disability includes an undiagnosed illness, a medically unexplained chronic multi symptom illness (such as chronic fatigue syndrome, fibromyalgia, or functional gastrointestinal disorders), and a diagnosed illness that VA determines warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i). VA indeed must establish presumptive service connection for any illness determined to have a positive association with exposure to a biological, chemical, or other toxic agent, environmental or wartime hazard, or preventive medicine or vaccine associated with service in the Southwest Asia theater of operations during the Persian Gulf War. 38 U.S.C.A. § 1119(a)(2)(A). No such illnesses, to include those evaluated by the National Academy of Sciences, have been determined to have such an association to date. 76 Fed. Reg. 2447 (Jan. 13, 2011); 76 Fed. Reg. 21099 (Apr. 11, 2011). The Board must account for evidence which it finds to be persuasive or unpersuasive and provide reasons for rejecting any material evidence favorable to the Veteran. See Gabrielson v. Brown, 7 Vet. App. 36 (1994), Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, an assessment of the probative value of the lay evidence in addition to the medical evidence must be undertaken. Lay evidence indeed may be sufficient by itself to support a claim of service connection. Barr, 21 Vet. App. at 307. This is the case where the evidence is both competent and credible. Competency is "a legal concept determining whether testimony may be heard and considered" whereas credibility is "a factual determination going to the probative value of the evidence to be made after the evidence has been admitted." Layno v. Brown, 6. Vet. App. 465 (1994). A lay person is competent to provide testimony or statements relating to facts of events that the lay person observed or that is within the realm of his/her personal knowledge. Id. In weighing credibility, discounting of competent testimony or statements from a lay person may occur "in the light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). Factors for consideration therefore include a showing of interest, self-interest, bias, inconsistent statements, inconsistency with other evidence of record, facial implausibility, bad character, malingering, desire for monetary gain, and witness demeanor. See Pond v. West, 12 Vet. App. 341 (1999); Macarubbo v. Gober, 10 Vet. App. 388 (1997); Caluza v. Brown, 7 Vet. App. 498 (1995); Cartright v. Derwinski, 2 Vet. App. 24 (1991). "[T]he Board cannot determine that lay testimony or a lay statement lacks credibility merely because it is unaccompanied by contemporaneous medical evidence." Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, the lack of such evidence in combination with other factors may lead to the determination the lay testimony or statement is not credible. The benefit of the doubt is given to the Veteran when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. As such, the Veteran prevails when the evidence supports his claim or is in relative equipoise but does not prevail when the preponderance of the evidence is against the claim. Id. Although all the evidence has been reviewed, only the most salient and relevant evidence is discussed herein. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). The Veteran's DD-214 shows that he served from August 1990 to June 1992 in support of Operation Desert Shield/Storm. It also shows that he had just shy of three years of foreign service. The Veteran's service personnel records contain a series of performance reports. These reports denote that he was stationed at Kadena Air Base in Japan from some point in 1983 or 1984 to some point in 1986 and at Minot Air Force Base (AFB) in North Dakota from some point in 1986 until his discharge in June 1992. A service personnel record dated in August 1991 additionally shows that the Veteran performed as the on-scene commander until a superior's arrival during a possible environmental hazard at a launch facility. This included evacuating civilians from inside the cordon and maintaining cordon integrity to minimize the threat to the public. Service treatment records do not reflect the Veteran's presence in Saudi Arabia or Bahrain. They rather reflect the following. The Veteran indicated that he was in good health and denied swollen or painful joints, liver trouble, and frequent trouble sleeping in May 1982. His abdomen and viscera were found to be normal then. The Veteran reported inhalation of chemical vapors the previous day, but no current health complaints, in April 1991. He was noted to have been exposed to hydrazine at a B-9 missile site on Minot AFB in North Dakota. After physical assessment, he was diagnosed with hydrazine exposure and sinusitis. He was placed on sick call to go home and rest and was told to return if he had respiratory difficulties or any other symptoms. From May 1991 until his discharge in June 1992 the Veteran did not complain of, obtain treatment for, or receive a diagnosis of any liver problem, to include fatigue or joint pain. No separation examination was performed due to "shortness in time." Private treatment records document the following. In June 2001, the Veteran reported a decrease in his back pain. In September 2005, he complained of hip and back pain, a painful spot when his abdomen was pressed on, and increased abdominal pressure. Diagnoses of constipation, chronic constipation, and abdominal hernia were rendered. The Veteran continued to complain of fatigue and a dull ache in his abdomen in October 2005. Lab results revealed abnormal liver function tests (LFTs) but no hepatitis. Abnormal LFTs and abdominal pain/constipation were diagnosed. Also in October 2005, an abdominal ultrasound showed that the Veteran's liver was unremarkable with the exception of a small hepatic cyst in the right lobe. A diagnosis of abnormal LFTs was made in November 2005. This was noted to potentially be from a fatty liver, though hemachromatosis could not definitely be ruled out, early that month. Later that month, it was noted to most probably be from fatty liver because the Veteran "needs to lose weight." Extreme fatigue and severe back pain were reported by him at this latter time. In March 2007, the Veteran again reported fatigue/malaise. Lab results showed increased liver function, as liver enzymes were elevated. Alcohol use, fatty liver, and "gallbladder s/s" each were indicated as questionable. In April 2007, the Veteran continued to be fatigued. He noted that he was supposed to have a liver biopsy but had not followed up with the doctor who was to perform it. He also voiced his concern that his liver problems were related to his military hydrazine exposure. A computerized tomography (CT) scan of his abdomen reflected hepatic cysts, but otherwise was negative. Lab results continued to show liver enzyme elevation. It was noted that this did not appear to be hemachromatosis. Diagnoses of elevated liver enzymes (chronic) and chronic fatigue were made. Etiology was noted to be questionable. Finally, the Veteran reiterated his concern regarding a link between his military hydrazine exposure and his liver problems as well as his complaint of fatigue in May 2007. A list of his past medical illnesses included "fatty liver 2002." Lab results revealed that previously found elevated transaminases had normalized and that viral and iron studies were negative, though ceruloplasmin was somewhat low. Non-alcoholic steatohepatitis (NASH) was identified as the most likely diagnosis "given [the Veteran's] obesity ([body mass index] 34). The role of his chemical exposure is not entirely known." In a letter dated in July 2007, S.G., MSN, FNP, indicated that she had been treating the Veteran since September 2006. S.G. then indicated that he had a history of abnormal blood chemistries with continued complaint of chronic fatigue. She noted that laboratory findings from March 2007 revealed elevated liver functions and that a subsequent CT scan of the Veteran's abdomen showed hepatic cysts. The Veteran indicated in a July 2007 statement that he was exposed to monomethyl hydrazine for a period of time over an hour. He then indicated that he remained in the area several hours thereafter assisting with the evacuation effort. A request was made via the Personnel Information Exchange System (PIES) to verify the Veteran's service in Southwest Asia in mid-September 2007. The response received later that month was that "there is no evidence in the record that indicate the Veteran served in Southwest Asia." In an October 2007 statement, the Veteran asserted that he served in "Saudi Arabia (Bahrain)" from October 1991 to January 1992. He attached four photos to this statement which he purported were taken there. Two of these pictures were noted by the Veteran to be of a sandstorm in September 1991. One of the other two is of him and was noted by him to have been taken around Christmas 1991. The last picture is of a sunset and is undated. The Veteran disputed that he was obese in his October 2008 notice of disagreement. He noted that he was five feet eight and one half inches tall and 220 pounds, but had large bones and "upper muscle build." In a letter dated in July 2009, S.G. reiterated that she had been treating the Veteran since September 2006. She recounted that he presented with fatigue/malaise and diffuse arthralgias and myalgias at that time and reported a lengthy history of these symptoms after he returned from deployment during the Persian Gulf War in 1991, where he had significant exposure to methyl hydrazine. Next, she noted that the Veteran has had consistent elevation of his serum transaminases and that he was diagnosed with NASH. She also noted that CT scans of his abdomen show the presence of cysts in the liver consistent with this condition. Finally, she stated that "many patients with this condition are asymptomatic for many years and only begin to develop non-specific symptoms such as fatigue, malaise[,] weight-loss[,] and weakness as the disease advances." Along with this letter is an undated prescription page from S.G. in which she diagnosed chronic noninfectious hepatitis. The Veteran's liver was found to be normal at a May 2011 VA general medical examination conducted with respect to another matter. Private treatment records dated in 2011 document the following. A June 2011 liver biopsy mild macrovesicular steatosis with prominent dilation of portal veins in virtually every portal tract as well as minimal associated inflammation without significant sclerosis. It was noted that, given the Veteran's history of methyl hydrazine exposure, these nonspecific findings "could conceivably be seen with hepatoportal sclerosis which may be idiopathic or associated with drugs, malignancy, etc." A component of portal hypertension also could not be excluded. Fatty liver with elevated liver enzymes and elevated unconjugated hyperbilirubinemia, methyl hydrazine exposure while in the military in 1991, as well as obesity were diagnosed in July. It was noted that "there is very little at in (sic) the liver" as "the only thing abnormal" was the nonspecific finding of prominent dilation of portal veins in virtually every portal tract present. It was opined that chemical exposure causing this liver problem could not excluded totally. Finally, it was noted that whether this liver problem is causing elevated liver enzymes is still indeterminate. A repeat liver biopsy every three to five years as well as weight reduction was recommended The Veteran reported that his exposure to monomethyl hydrazine lasted at least 15 minutes, but that he had to remain on site for 10 hours, at the March 2012 VA liver, gall bladder, and pancreas examination. NASH was diagnosed by the examiner. The examiner indicated that fatty liver was a problem associated with this diagnosis and that fatigue seemed to be attributable to the Veteran's psychiatric problems. Finally, the examiner opined that whether the Veteran's NASH was related to his exposure to monomethyl hydrazine could not be resolved without resort to mere speculation. Noted in this regard was that extensive review of research on hydrazine exposure had been undertaken. A website was cited. The examiner highlighted that the Veteran had acute rather than chronic exposure. Also highlighted was that animal studies showed chronic exposure resulted in liver disease and steatosis but that acute exposures caused symptoms such as tremor and did not cause liver changes. Further highlighted was that no studies identified the results of acute exposure in humans. The examiner thus indicated that the effect of such exposure on the liver in humans is unknown. Finally, the examiner indicated that this effect may become clearer in the future with further research. Given the above, the Board finds that service connection for a liver disability is not warranted. All necessary requirements for establishing entitlement to this benefit are not met. A current disability exists when there is a disability when a claim for it is filed or at any time during the pendency of such claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007). The Veteran submitted his claim in May 2007. Contemporaneous to and since that time, there has been conflict regarding whether he has a liver problem. His liver was found to be normal on one occasion. It was noted on another occasion to have "very little" abnormality. Abnormality in the form of prominent dilation of portal veins in virtually every portal tract present existed then, however. Diagnoses of elevated liver enzymes (chronic), chronic fatigue, NASH, fatty liver with elevated liver enzymes and elevated unconjugated hyperbilirubinemia, and chronic noninfectious hepatitis further have been made. The preponderance of the evidence therefore shows a current liver problem. Consideration next is given to whether any of the aforementioned current diagnoses constitute a liver disability. A laboratory finding is an indication of an injury or disease which could result in disability rather than a disability in and of itself. See 61 Fed. Reg. 20,440 (May 7, 1996) (discussing hyperlipidemia, elevated triglycerides, and elevated cholesterol). A symptom also is an indication of an injury or disease which could result in disability rather than a disability in and of itself. Indeed, symptom is defined as "evidence of disease." See Merriam-Webster's Collegiate Dictionary, 1267 (11th ed. 2003); see also Dorland's Illustrated Medical Dictionary, 1843 (31st ed. 2007). "Pain alone ... does not in and of itself constitute a disability," for example, absent "a diagnosed or identifiable underlying disease or injury." Sanchez-Benitez v. West, 13 Vet. App. 282 (1999) (dismissed in part and vacated in part on other grounds in Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001)). The aforementioned diagnosed laboratory findings concerning elevated liver enzymes, elevated unconjugated hyperbilirubinemia, and fatty liver as well as the abnormality of prominent dilation of portal veins in virtually every portal tract present therefore do not signify a disability. The aforementioned diagnosed symptom of chronic fatigue also therefore does not signify a disability. That leaves NASH and chronic noninfectious hepatitis, neither of which is a laboratory finding or a symptom. Both of these diagnoses therefore signify a disability. This determination renders it unnecessary to proceed to consider the other non-diagnosed findings of record. Additionally, the diagnoses of NASH and chronic noninfectious hepatitis render inapplicable the special service connection rules for Persian Gulf Veterans. Fatigue and joint pain are objective indications of a qualifying chronic disability. Yet there cannot be an undiagnosed illness related to the liver, even if it encompasses fatigue and joint pain, given the aforementioned diagnoses. There also is no medically unexplained chronic multi symptom illness at issue. At no point has the Veteran's fatigue and joint pain been deemed symptoms of a medically unexplained chronic illness such as chronic fatigue syndrome, fibromyalgia, or any functional gastrointestinal disorder. It is acknowledged that none of these examples of such an illness specifically concerns the liver. Yet the existence of such a medical unexplained chronic liver illness with symptoms of fatigue and joint pain has not even been suggested here. This matter is one of incurrence of an injury or disease during service rather than aggravation of a preexisting injury or disease during service. A Veteran is presumed to be in sound condition upon entry into service except as to defects, infirmities, or disorders noted at that time or where clear and unmistakable evidence demonstrates that an injury or disease existed prior to service and was not aggravated by such service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Noted means "[o]nly such conditions as are recorded in examination reports." 38 C.F.R. § 3.304(b). Here, no liver problem was noted upon examination in May 1982 near the time the Veteran commenced his active duty service. This is not surprising, as he did not report any such problem or symptoms of such a problem at that time. Service treatment records are silent with respect to any liver problem as well as to symptoms thereof. Thus, no chronic liver disease has been shown during the Veteran's active duty service. He has contended that he experienced symptoms of a liver problem, to include fatigue and joint pain, following in-service exposure either to environmental hazards and carcinogens in Saudi Arabia or Bahrain during the Persian Gulf War from October 1991 to January 1992 or to monomethyl hydrazine in April 1991, however. He is competent to so contend because these symptoms and events would have been experienced by him. Layno, 6. Vet. App. at 465. He is not credible regarding exposure to environmental hazards and carcinogens in Southwest Asia but is credible regarding exposure to monomethyl hydrazine. See Buchanan, 451 F.3d at 1331; Pond, 12 Vet. App. at 341; Macarubbo, 10 Vet. App. at 388; Caluza, 7 Vet. App. at 498; Cartright, 2 Vet. App. at 24. It is facially plausible that the Veteran had in-service exposure to environmental hazards and carcinogens in Saudi Arabia or Bahrain during the Persian Gulf War. That the latter portion of his active duty service from January 1982 to June 1992, to include that from October 1991 to January 1992, was during the Persian Gulf era is undisputed. See 38 U.S.C.A. § 101(33); 38 C.F.R. § 3.2 (both defining the Persian Gulf War as beginning on August 2, 1990, and ending on a date thereafter to be prescribed by Presidential proclamation or law). However, his assertion of being stationed in Saudi Arabia or Bahrain during this portion of his active duty service is inconsistent with the other evidence. Service treatment and personnel records as well as his do not show that he was in Saudi Arabia or Bahrain then. They rather show that the Veteran was at Minot AFB in North Dakota from August 1990 to his separation in support of Operation Desert Shield/Storm. His three years of foreign service, instead of being in Saudi Arabia or Bahrain during the Persian Gulf War, indeed was at Kadena Air Base in Japan in the early to mid 1980's. A PIES request further resulted in a response that there is no evidence that he served in Southwest Asia. It is reiterated that Southwest Asia includes both Saudi Arabia and Bahrain. 38 C.F.R. § 3.317(e)(2). Further, none of the four photos submitted by the Veteran proves service in Saudi Arabia or Bahrain. The two photos reported by him to be a sandstorm were taken in September 1991, a month prior to the time he contends he started serving in these countries. The photo of the Veteran was reported by him to have been taken during the correct timeframe of late 1991, but it does not contain sufficient detail to identify location. The sunset photo is undated and further does not contain sufficient detail to identify location. The Veteran's self-interest in gaining financially further cannot be ignored. If his assertion that he served in Saudi Arabia or Bahrain during the Persian Gulf War is found to be both competent and credible, it is more likely that service connection will be granted. Such a grant potentially could result in his receipt of VA compensation benefits. In sum, service in Saudi Arabia or Bahrain during the Persian Gulf War has not been established. It follows that exposure to environmental hazards and carcinogens during service there also has not been established. It also follows, for this reason in addition to those discussed above, that the special service connection rules for Persian Gulf Veterans are inapplicable. It is facially plausible that the Veteran was exposed to monomethyl hydrazine in April 1991 during his active duty service. Moreover, his assertion in this regard is consistent with the other evidence. A service personnel record mentions a possible environmental hazard. An April 1991 service treatment record reflects the Veteran's exposure to hydrazine. His self-interest in gaining financially thus does not undermine his veracity. Accordingly, in-service exposure to monomethyl hydrazine, or at least hydrazine, has been established. The post-service diagnosis of methyl hydrazine exposure while in the military in 1991 therefore is confirmed as accurate. Undisputed is that the Veteran served more than 90 days during a period of war after December 31, 1946. His service spanned over 10 years. Almost two years was during the Persian Gulf era. Yet there is no indication that the Veteran manifested the chronic disease of cirrhosis of the liver to a compensable degree within one year from June 1992 when he separated from service. Absent is any reference to cirrhosis whatsoever during the June 1992 to June 1993 timeframe. Indeed, absent is any reference to cirrhosis whatsoever at any point. Service connection therefore turns on whether or not the Veteran's current liver disability is attributable, to include through continuity of symptomatology indicative of a liver problem, to his in-service exposure to monomethyl hydrazine. The weight of the evidence does not show this to be the case. Three medical opinions are of record. One medical opinion is that the possibility that exposure to the chemical methyl hydrazine caused the Veteran's current liver problem of prominent dilation of portal veins in virtually every portal tract present could not be excluded totally. Of note is that this opinion concerns a diagnosed laboratory finding rather that one of the diagnosed conditions comprising his current liver disability. Even assuming that the opinion did concern his current liver disability instead of merely a laboratory finding, it suffers from a fatal flaw. While not negative, this opinion is a far cry from positive. It indeed does not rise anywhere near the level of finding that the Veteran's in-service exposure to monomethyl hydrazine even at least as likely as not caused his current liver disability. The opinion acknowledges the possibility that such exposure caused his current liver disability. Yet it goes not further. "Remote possibility" is not a sufficient basis for resolving the benefit of the doubt in favor of the Veteran with respect to service origin. See 38 C.F.R. § 3.102 (distinguishing from "within the range of probability"). A second medical opinion is that the role of the Veteran's exposure to the chemical hydrazine in causing NASH is not entirely known. This opinion, unlike the opinion above, concerns one of the diagnosed conditions comprising his current liver disability rather than a symptom or a laboratory finding indicative thereof. Yet like the above opinion, it suffers from the fatal flaw of failing to rise anywhere near the level of even at as likely as not. Of note is that it further suggests the obesity for etiology. Given that it simply is a suggestion, discussion in this regard of great detail is unnecessary. It is sufficient to note that, despite the Veteran's assertion that to the contrary, he has been diagnosed as obese. The only other existing medical opinion concerning in-service etiology is neither positive nor negative. Specifically, it was opined upon VA examination that whether or not the Veteran's NASH is related to his in-service exposure to monomethyl hydrazine could not be resolved without resort to mere speculation. "An examiner's conclusion that a[n] ... etiology opinion is not possible without resort to speculation is a medical conclusion just as much as a ... conclusive [etiology] opinion." Jones v. Shinseki, 23 Vet. App. 382 (2010). A few instances in which etiology cannot be determined indeed have been identified. One such instance is "limits to even the most current medical knowledge." Id. Here, the examiner cited the present state of relevant research as the reason for being unable to provide a conclusive etiology opinion. In light of this instance and the others in which etiology cannot be determined, VA need not "proceed through multiple iterations of repetitive medical examinations until it obtains a conclusive opinion or formally declares that further examinations would be futile." Id. An examiner cannot invoke "the phrase 'without resort to mere speculation' as a substitute for the full consideration of" the evidence, however. Id. Reliance on the examiner's conclusion therefore requires finding that it was made after consideration of "all procurable and assembled data." Id. Reliance on the examiner's opinion further requires that the basis for it be provided or otherwise be apparent from a review of the record. Id. The examiner's opinion followed the examiner's review of the claims file and medical evidence located elsewhere such as in the "eFolder," as discussed above. This included all pertinent evidence available as of that time such as the Veteran's service treatment records, DD-214 and service personnel records, private treatment records, irrelevant VA treatment records, and statements/other claims documentation. This also included the Board's March 2011 remand setting forth the Veteran's contentions. Finally, this also likely included the 2011 private treatment records later submitted. It follows that "all assembled data" was considered. It also follows that the opinion involved consideration of continuity of liver symptoms as asserted by the Veteran and to the extent established by the record. In addition, the examiner extensively reviewed available research on hydrazine exposure. It follows that "all procurable data" was considered. The examiner discussed that the Veteran's exposure to hydrazine was acute rather than chronic. Then, the examiner set forth findings from animal studies showing liver changes from chronic but not acute exposure as well as noted a lack of studies regarding the effects of acute exposure in humans. The need for future research in this regard was identified. All told, this actions covered about one half of a page. The basis for the opinion thus was set forth. Because the two aforementioned requirements have been met, the Board may rely on the examiner's opinion. No positive medical opinion countering it exists. The only other evidence doing so indeed is from the Veteran. Specifically, he believes that his current liver disability is related to his in-service exposure to monomethyl hydrazine. Such a belief sometimes is sufficient to establish a relationship to service. See Davidson v. Shinseki, 581 F.3d at 1313 (Fed. Cir. 2009) (quoting Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007), specifically Jandreau v. Nicholson, No. 04-1254, 2006 WL 2805545, at *3 (Vet. App. Aug. 24, 2006)) (alterations in original) as follows: "explicitly rejected [is] the view ... that 'competent medical evidence is required ... [when] the determinative issue involves ... medical etiology'"). It indeed is error to suggest that lay evidence can never be sufficient to satisfy the requirement that there be a nexus between a claimed condition and service. See Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). The question of whether there exists a service etiology in this case is medical in nature, however. Of note in this regard are the complexities of the digestive system, the numerous potential causes of liver problems and disabilities, and the number of years that have passed since the Veteran's active duty service. Only those with specialized medical knowledge, training, and/or experience therefore are competent to answer the above question. See Jones v. West, 12 Vet. App. 460 (1999). The Veteran, as a layperson without such knowledge, training, and/or experience, is not competent to render an opinion that there exists a relationship between his service and his current liver disability. See Cromley v. Brown, 7 Vet. App. 376 (1995); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The preponderance of the evidence, in sum, is against the Veteran's entitlement to service connection for a liver disability under all pertinent theories of entitlement. Accordingly, the benefit of the doubt is inapplicable and this benefit is denied. ORDER Service connection for a liver disability is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs