93 Decision Citation: BVA 93-03483 Y93 BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 DOCKET NO. 91-47 764 ) DATE ) ) ) THE ISSUES Entitlement to service connection for residuals of cholecystectomy. Entitlement to an increased rating for residuals of subtotal colectomy and amebiasis, currently rated as 20 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD R. K. ErkenBrack, Counsel INTRODUCTION This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision in December 1990 of the Department of Veterans Affairs (VA) Regional Office (RO) at Seattle, Washington. The veteran served on active duty for training from September 1958 to March 1959 and on active duty from April 1959 to November 1978. The notice of disagreement was received in January 1991. The statement of the case was issued in February 1991. The substantive appeal was received in March 1991. A hearing was held before a hearing officer at the RO in March 1991. A supplemental statement of the case was issued in July 1991. The veteran has been represented throughout his appeal by Disabled American Veterans, which presented a statement on the appeal at the RO in September 1991. The appeal was received at the Board in November 1991. Disabled American Veterans submitted additional written argument to the Board in March 1992. The case is ready for appellate review as to the service connection issue. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, in substance, that his cholecystectomy was caused by the service-connected residuals of subtotal colectomy. He reports that the reason for the cholecystectomy first was thought to be gallstones but the operation revealed that the gallbladder was encased in old scar tissue from the subtotal colectomy. He argues that the constriction from the old scar tissue rendered the gall bladder dysfunctional to the point where the cholecystectomy became necessary. In other words, the veteran feels that, but for the service-connected residuals of the subtotal colectomy, the cholecystectomy would not have been necessary. DECISION OF THE BOARD In accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), following review and consideration of all evidence and material of record in the claims file, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence favors the claim that the veteran's cholecystectomy resulted from service-connected residuals of subtotal colectomy with amebiasis. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. A cholecystectomy was made necessary by cholelithiasis (gallstones) with symptoms of subcostal abdominal pain, pain characteristic of gallbladder colic, altered liver function, attacks of gallbladder colic pain 2 to 3 times a week and a finding of multiple gallstones which were first detected many years following service. 3. The cholecystectomy required for cholelithiasis was as likely as not predisposed by encasing scarification from the service-connected subtotal colectomy because it served to induce gallbladder hypomotility with delayed emptying and stasis. CONCLUSION OF LAW Cholelithiasis necessitating cholecystectomy was proximately due to or the result of service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107(a) (West 1991); 38 C.F.R. § 3.310(a) (1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The legal and factual issues presented on the record are: Whether cholelithiasis which necessitated a cholecystectomy was secondary to and the result of service-connected residuals of subtotal colectomy? We find that the veteran's claims are "well-grounded" within the meaning of 38 U.S.C.A. § 5107(a). That is, we find that he has presented plausible claims. We are also satisfied that all relevant facts have been properly developed. No further assistance is required to comply with the duty to assist him mandated by 38 U.S.C.A. § 5107(a). The service medical records show that the veteran had no complaint, finding or diagnosis of cholelithiasis in service. In July 1976 he complained of stomach cramps, vomiting, tightness and acute pain in the lower abdomen with urinary burning. There was tenderness in the right periumbilical area. Cholelithiasis and kidney stones were to be ruled out. X-ray analysis was unremarkable. In July 1976, the veteran had presented with a two-day history of right lower quadrant pain and tenderness. The veteran underwent exploration through an extended right lower quadrant transverse incision. At the time of the operation appendicitis was found as well as an appendiceal tumor which extended into the cecum. It was elected at the time of operation to do a right colectomy because the nature of the tumor was undetermined and an ileostomy and transverse colon mucus fistula were carried out. Postoperatively, he did well. His wounds healed normally. The final diagnoses were benign mucosal polyps of the cecum, acute and chronic appendicitis, mucocele of the appendix and diverticulum of the appendix. The veteran returned in mid-October 1976 complaining of vague epigastric pain. He underwent an intensive workup of his pain. At that time, various tests, including oral cholecystogram, were within normal limits. Physical evaluation board proceedings and findings, completed in September 1978, show the final diagnosis of abdominal pain, etiology undetermined, probably secondary to previous right hemicolectomy for mucocele of the appendix and chronic diarrhea. The positive findings were restricted to tenderness to deep palpation in the right lower quadrant. He had been complaining of intractable right lower quadrant pain and watery diarrhea. There were well-healed transverse abdominal scars with no incisional or inguinal herniae. Oral cholecystogram was within normal limits. A normal endoscopic retrograde pancreatocholangiogram was also obtained. On a VA examination in January 1979, the veteran complained of lower pain in his stomach from surgery. He weighed 220 pounds and had had no recent weight loss. He was 6 feet 2 inches tall. The abdomen revealed scars from surgery. There was some tenderness on deep pressure over the right upper quadrant. There was no recurrence of hernia. The pertinent diagnosis was status post colectomy with resulting chronic diarrhea, under treatment. In June 1981, the veteran was at the Mason Clinic for tests including stool studies and small bowel and upper gastrointestinal X-ray studies, all of which were negative for any active symptoms of amebiasis. A private physician's small bowel follow study on the veteran in December 1984 indicated status post right hemicolectomy and rapid small bowel transit with no evidence of mechanical obstruction. The veteran reportedly had choleretic enteropathy secondary to the old ileal right hemicolectomy as had been previously indicated in May 1982 and suggested as a possibility in June 1981. The veteran was hospitalized at Harrison Memorial Hospital in April 1990 with a longstanding history of subcostal colicky abdominal pain usually associated with a big meal. The pain had the characteristic presentation of gallbladder colic and recent liver function showed alteration. Subsequent ultrasound showed the presence of multiple gallstones. Surgery was advised and performed, revealing that the right upper quadrant was completely sealed over by previous surgery, which had involved resection of the terminal ileum and right colon, preceded with right colostomy. This required a tedious dissection to free away the adhesions and finally the gallbladder was exposed and shown to be encased in a massive pericholecystic adhesion either from previous surgery or from history of chronic cholecystitis. The gallbladder was baggy, distended and contained multiple stones. The exploration otherwise was not very satisfactory because the abdominal cavity was sealed over by extensive adhesions. Cholecystectomy was performed and the cholangiogram showed free flow of dye in the duodenum without filling defect. The clinically identified indications for the cholecystectomy had been subcostal colicky abdominal pain with characteristic gallbladder colic, altered liver function, and ultrasound findings of multiple gallstones. The preoperative diagnosis had been chronic cholecystitis with cholelithiasis and the operation performed had been cholecystectomy and operative cholangiogram. The possibility was entertained in the operative report that the adhesions encapsulating the gall bladder may have been induced by cholecystitis. On a VA examination in August 1990, a history of inservice hemicolectomy and amebiasis was recorded. Since that time, the veteran reported normally having had 2 or 3 somewhat loose bowel movements a day, on medication, but 4 or 5 a day without it. Following his gallbladder surgery, his weight had remained steady at about 205 pounds. He had worked regularly in a shipyard and had lost no time from his employment except for when he had had his gallbladder surgery in April 1990. He was active physically; maintained his lawn; landscaped; cut trees, etc. There was an 8-inch well-healed surgical scar in the right subcostal area and a 12-inch well-healed surgical scar in the midline of the epigastrium and hypogastrium, extending into the right lower quadrant. The impressions included status post right subtotal colectomy for appendicitis and mucocele of the appendix, status post cholecystectomy for cholelithiasis, and status post amebiasis without recurrent symptoms. A transcript (T.) of the March 1991 hearing at the RO is of record. The veteran stated that he had always had abdominal pain which got worse if he went out and really exerted himself; received continuous treatment for it; and was nauseous at least once a day. T. at 2. He reportedly was colicky all the time. T. at 3. What led up to the April 1990 surgery in the veteran's words was that the veteran was found to have an abnormal reading in his liver count; an ultrasound was scheduled; and the ultrasound revealed gallstones. T. at 5. He recalled having been told about the amount of scar tissue that had been encountered and lysed; and that his rib cage had to be moved out of the way to get to the scar tissue so that the gallbladder could be removed. He stated that the scar tissue was cutting-off the gallbladder; that he still had some pains after the cholecystectomy; and that he had colicky feelings and diarrhea, which had continued despite surgery. T. at 6. He complained of daily diarrhea, unrelieved from medication. A doctor reportedly had told him that scar tissue was impairing his gallbladder and that it would have had to be removed anyway because of the scar tissue. T. at 7. It was believed that the veteran deserved a 50 percent disability evaluation for peritoneal adhesions because of severe definite partial obstruction shown by X-ray with frequent and prolonged episodes of severe colic distention, nausea, or vomiting following severe peritonitis, a ruptured appendix, a perforated ulcer or operation with drainage. The veteran reportedly fitted at least three of the criteria for the 50 percent evaluation. It was believed that the gallbladder should be service-connected secondary to the peritoneal adhesions caused by the colectomy performed during service. T. at 11-12. On a VA examination in April 1991, it was stated that the veteran had incurred amebiasis in Vietnam in about 1966; was treated; and there were no residual symptoms. The subtotal colectomy in 1976 was noted. There was a 5-inch well-healed surgical scar in the right upper quadrant. There was a long midline surgical scar which extended into the right lower quadrant. The abdomen was soft and nontender. There was no distention. No masses or organomegaly were present. The veteran was 6 feet 1 inch tall and weighed 216 pounds with excellent nutrition. The impressions were status post amebiasis in 1966, treated, with no residual symptoms, status post excision of a mucocele of the colon in 1976 with residual loose bowel movements, but also with an excellent state of nutrition without any prior evidence of bowel obstruction, and status post cholecystectomy for cholelithiasis in April 1990. It appears clear that the cholecystectomy was necessitated by cholelithiasis (gallstones). The veteran has argued that the scar formation (peritoneal adhesions) from the inservice abdominal surgery somehow interfered with gall bladder function so as to have been a factor in eventual cholecystectomy. Gallstones are crystalline structures formed by concretion or accretion of normal or abnormal bile constituents. Cholesterol and mixed stones account for 80 percent of the total. Pigment stones comprise the remaining 20 percent. High caloric diet, drugs, impaired hepatic conversion of cholesterol soluble acids, decreased hepatic secretions, defective vesicle formation, biliary sludge, gallbladder hypomotility due to surgery, which causes delayed emptying and stasis are predisposing factors for gallstone formation. HARRISON'S PRINCIPLES OF INTERNAL MEDICINE 1359-60 (12th ed. 1991). The gallbladder was described as encased in extensive scarification, which certainly was accompanied by changes indicative of hypomotility and gallstone formation. Stasis of bile due to adhesions could result in the development of gallstones. Private physicians had felt that the veteran's choleretic enteropathy was due to the old ileal right hemicolectomy. Additionally, there are applicable medical principles supporting the claimed etiological relationship, as follows: Resection of the distal small intestine may cause serious diarrhea and steatorrhea. Conjugated bile salts, essential for normal fat absorption, are absorbed most effectively by an active transport mechanism present only in the ileum. Reduction or complete removal of these active absorptive sites in patients who have undergone ileal resection disrupts the enterohepatic circulation of bile salts (...). If less than 100 cm of the distal part of the ileum has been resected, watery diarrhea termed cholerrheic diarrhea with little or no steatorrhea usually results. Although increased amounts of bile salts reach the colon, hepatic synthesis compensates sufficiently to maintain adequate concentrations of bile salts in the lumen of the proximal portion of the intestine for normal digestion and absorption of dietary fats to proceed. Hovever, the excessive dihydroxy bile salts (chenodeoxycholate and deoxycholate) that enter the colon not only impair water and ion absorption but actually stimulate their secretion by the colonic mucosa when they are present in concentrations greater than 3mM...The mechanisms responsible for cholerrheic diarrhea are not fully understood, but increased mucosal cyclic adenosine monophosphate (cAMP) levels and direct damage by bile salts to the epithelium have been implicated... If more than 100 cm of ileum has been resected, bile salt loss in the stool is so large that even maximum hepatic synthesis in unable to maintain a sufficient bile salt pool for normal intraluminal micellar solubilization of dietary fat. As a result, fat is malabsorbed in the remaining small intestine... It has been well documented that ileal disease and ileal resection result in lithogenic bile, presumably caused by depletion of the bile salt pool. Indeed, it has been reported that the frequency of gallstones in patients with partial or total ileal resection is 25 to 32 per cent, approximately three times that of control populations... Gastrointestinal Disease Pathophysiology Diagnosis Management 1107-1108 (4th ed. 1989). Gallstones also occur more frequently in patients with severe bile acid malabsorption. Their pathogenesis is likely to involve a deficiency of bile acids in the biliary tree. This in turn leads to defective solubilization of cholesterol, causing cholesterol gallstones or defective complexation of calcium, causing calcium carbonate gallstones. Id 154. We find, therefore, that it is at least as likely as not that the extensive peritoneal adhesions from inservice abdominal surgery for subtotal ileal colectomy predisposed the eventual development of gallstones necessitating cholecystectomy. ORDER Service connection for residuals of cholecystectomy is granted. REMAND In view of the grant of service connection for residuals of cholecystectomy, this case is remanded on the increased rating issue for evaluation of the combined conditions pursuant to 38 C.F.R. § 4.114 (1991) with consideration of Diagnostic Codes 7301, 7318 and 7329 of 38 C.F.R. Part 4. When the above rating action has been accomplished, if the claim remains denied, the appellant and his representative should be furnished copies of the supplemental statement of (CONTINUED ON NEXT PAGE) the case and an opportunity to reply thereto, and the claims file should be returned to the Board by the RO, if still in order. The purpose of this Remand is to permit the RO to evaluate the enlarged service-connected disabilities. BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 * J. E. DAY (MEMBER TEMPORARILY ABSENT) SAMUEL W. WARNER *38 U.S.C.A. § 7102(a)(2)(A) (West 1991) permits a Board of Veterans' Appeals Section, upon direction of the Chairman of the Board, to proceed with the transaction of business without awaiting assignment of an additional Member to the Section when the Section is composed of fewer than three Members due to absence of a Member, vacancy on the Board or inability of the Member assigned to the Section to serve on the panel. The Chairman has directed that the Section proceed with the transaction of business, including the issuance of decisions, without awaiting the assignment of a third Member.