Citation Nr: 9901994 Decision Date: 01/26/99 Archive Date: 02/01/99 DOCKET NO. 96-28 226 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to an increased rating for duodenal ulcer, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD H. Roberts, Associate Counsel INTRODUCTION The veteran served on active duty from February 1942 to June 1944. This appeal arises before the Board of Veterans’ Appeals (Board) from a December 1995 rating decision of the Nashville, Tennessee, Regional Office (RO) of the Department of Veterans Affairs (VA), which denied the issue on appeal. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the veteran’s claim has been developed. 2. The veteran’s duodenal ulcer is not productive of impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging ten days or more in duration at least four or more times a year. CONCLUSION OF LAW The criteria for entitlement to an increased rating, greater than 20 percent, for duodenal ulcer are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, § 4.114, Diagnostic Code 7305 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, the Board finds that the veteran’s claim is “well grounded” within the meaning of 38 U.S.C.A. § 5107(a) (West 1991); that is, he has presented a claim that is plausible. He has not alleged that there are any records of probative value that may be obtained which have not already been associated with his claims folder. The Board accordingly finds that the duty to assist the veteran, as mandated by 38 U.S.C.A. § 5107(a) (West 1991), has been satisfied. The veteran contends that his duodenal ulcer is more severe than currently evaluated, warranting an increased rating. After a review of the record, the Board finds that the veteran’s contentions are not supported by the evidence, and his claim is denied. The veteran established service connection for chronic ulcer of the duodenum by means of a June 1944 rating decision, which assigned a 10 percent disability rating. The veteran established an increased rating of 20 percent for duodenal ulcer by means of an October 1993 rating decision. That rating was continued by a December 1995 rating decision, which is the subject of this appeal. The severity of a disability is ascertained, for VA rating purposes, by application of the criteria set forth in VA’s Schedule for Rating Disabilities, 38 C.F.R. Part 4 (1998) (Schedule). Duodenal ulcer is evaluated pursuant to the criteria found in Diagnostic Code 7305 of the Schedule. 38 C.F.R. § 4.114 (1998). Under those criteria, a rating of 20 percent is warranted where the evidence shows moderate duodenal ulcer with recurring episodes of severe symptoms two or three times a year averaging ten days in duration; or with continuous moderate manifestations. A rating of 40 percent is warranted where the evidence shows moderately severe duodenal ulcer, less than severe but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging ten days or more in duration at least four or more times a year. 38 C.F.R. § 4.114 (1998). Minor weight loss or greater losses of weight for periods of brief duration are not considered of importance in rating. Rather, weight loss becomes of importance where there is appreciable loss which is sustained over a period of time. In evaluating weight loss generally, consideration will be given not only to standard age, height, and weight tables, but also to the particular individual’s predominant weight pattern as reflected by the records. 38 C.F.R. § 4.112 (1998). A January 13, 1995, VA medical report notes that the veteran had some GI symptoms including fullness of the abdomen and recent strain from lifting. He was doing well. The veteran was characterized as obese. The abdomen was soft, and obese, and nontender with positive bowel sounds. The examiner provided an assessment of “stable med. problems.” A February 14, 1995, VA medical report shows that the veteran reported that Tylenol hurt his stomach and he requested Zantac instead of Tagamet. The veteran had been taken off Tagamet because it caused kidney problems. The veteran saw fresh blood in his stool two days prior. He also saw dark and black, tarry looking stools. An April 10, 1995, VA medical report notes that the veteran was generally alert and oriented times three. He was mildly overweight. The abdomen was soft, nontender, without masses, and without organomegaly. There was a negative Murphy’s sign, a negative iliopsoas sign, and there were normoactive bowel sounds. The examiner diagnosed peptic ulcers and started Zantac. An upper and lower GI series were scheduled. An April 13, 1995, radiology report of an X-ray of the colon with a barium enema revealed no delay in or obstruction of the passage of the medium through the cecum. Numerous diverticula affected the sigmoid colon and the descending colon with an occasional diverticulum also involving the descending colon. No evidence of associated diverticulitis was seen. No mass lesions were appreciated. The examiner provided an impression of diverticulosis of the colon, particularly the left. An April 18, 1995, radiology report of the esophagus, stomach, and duodenum by means of barium meal revealed no delay in or obstruction to the free flow of contrast material throughout the esophagus and stomach into the duodenum. An esophageal hiatal hernia was noted. Gastroesophageal reflux therein was seen. No changes of esophagitis were noted. Tertiary contractions of the esophagus were also present. The stomach and duodenum exhibited nothing unusual. Specifically, no evidence of inflammation, ulceration, or neoplasm was noted. The examiner provided impressions of esophageal hiatal hernia with demonstrable reflux, tertiary contractions of the esophagus, and otherwise normal upper GI series. A May 5, 1995, VA medical report shows that the veteran complained of soreness in the epigastric area with occasional nausea, but without vomiting. He was on Zantac. He noted loose stools, without rectal bleeding. His weight was 211. The examiner provided an assessment of hiatal hernia with gastroesophageal reflux disease. He was counseled on anti- reflux measures. He was counseled on a high fiber diet for diverticulosis. His anemia had resolved. An August 20, 1995, VA medical report shows that the veteran had mild dysuria, intermittent hesitancy, and occasional urinary or fecal incontinence. He had “nocturia x 2-3” and bowel movements were loose. He complained of weakness and rectal discomfort “way up in there.” There was “lots of rectal bleeding,” but none recently. A September 8, 1995, VA medical report shows that the veteran complained of vomiting twice. There were no fevers or chills, but he did have abdominal cramps. He was alert and oriented in no acute distress. The veteran complained of persistent stomach problems and his weight was 204. The abdomen was obese and soft with no organomegaly. There were positive bowel sounds, and no tenderness. The examiner diagnosed emesis, most likely related to whatever the patient ate the previous day. The veteran was advised to continue Zantac and keep his scheduled appointments. An October 20, 1995, VA medical report notes that the veteran had peptic ulcer disease, hiatal hernia with reflux, diverticulosis, and a history of hemorrhoids, anemia, and prostate cancer. The veterans weight was 209. He complained of occasional nausea and vomiting with positive abdominal pain. Zantac helped the symptoms. He had bright red rectal bleeding that morning in a loose bowel movement. He was drinking increased apple juice. The examiner noted that the history of diverticulosis had caused rectal bleeding before. A complete blood count on September 8, 1995, had shown no new findings. The examiner diagnosed diverticulosis, esophageal hiatal hernia, and gastroesophageal reflux with a history of prostate cancer. A December 29, 1995, VA medical report notes that the veteran had a history of peptic ulcer disease. He also had hiatal hernia with reflux and diverticulosis. He complained of increased epigastric burning. He had a history of anemia in 1994. He couldn’t eat anything and had no appetite. Temperature was normal after eating. The veteran was status post esophagogastroduodenoscopy in July 1995 for radiation proctitis, internal hemorrhoids, mild esophagitis, mild gastritis, and hiatal hernia. The veteran had dyspeptic symptoms in spite of Zantac. He was taking Mylanta. There was no vomiting. Bowel movements showed intermittent bleeding. The examiner proposed to rule out an obstruction. A December 29, 1995 radiology report revealed a normal intestinal gas pattern. No radiopaque urinary or gallbladder calculi were present. A January 19, 1996, VA medical report shows that the veteran complained of severe dysuria, severe urinary leakage, urgency, and nocturia 1-2. He also noted one fecal incontinence and suprapubic pain. The examiner diagnosed hiatal hernia and diverticulosis. A March 4, 1996, VA medical report shows that the veteran had a history of peptic ulcer disease and was taking Zantac. The veteran was being seen for neck pain and was prescribed Salsalate for that problem, which was to be discontinued if there was increased epigastric pain or bleeding. A January 9, 1997, VA stomach examination notes that the veteran was an 82-year old male with a history of duodenal ulcer disease dating more than 30 years. He complained of generalized mid-epigastric pain that had been intermittent for several months with associated episodes of diarrhea, of dark, tarry stools, and occasional vomiting. He denied hematemesis, but did complain of melena. He complained of generalized fatigue. He had been taking maintenance Zantac, Carafate, and Maalox. The veteran denied weight loss. In fact, he had gained approximately four pounds since his previous visit. He denied bleeding or bruising. He denied other related symptomatology. He did complain of pain between meals, relieved by eating or Maalox. Pain was always mid-epigastric, with occasional nausea. There were no other related constitutional symptoms. The examination revealed a well-developed, well-nourished elderly male. The abdomen was slightly protuberant. He had generalized mid-epigastric tenderness with voluntary guarding. There was no rebound tenderness. There were no other areas of tenderness. There was no mass or organomegaly. Bowel sounds were positive. The veteran’s weight was 203.75 pounds. The examiner provided an impression of peptic ulcer disease (duodenal). He recommended follow-up in the veteran’s primary care clinic, on a regular basis, and to continue the current therapeutic regime. The Board finds that the evidence does not show impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging ten days or more in duration at least four or more times a year, which would be required for a rating of 40 percent. The Board notes that the veteran’s weight has remained stable, at slightly over two hundred pounds and he had been characterized as obese and overweight. The most recent examination shows that the veteran had gained weight. The evidence clearly does not show weight loss as such is envisioned in the rating criteria. Furthermore, the evidence merely discusses that the veteran’s anemia had resolved. There are notations that the veteran had a history of anemia in 1994. The evidence does not show that the veteran had any current anemia. As neither weight loss nor anemia is shown, impairment of health manifested by anemia and weight loss is also not shown. Furthermore, the veteran’s medical records do not show incapacitating episodes averaging ten days in duration at least four times per year. The evidence does not show definite evidence of any incapacitating episodes. The Board finds that the veteran’s symptomatology more nearly approximates the criteria for a 20 percent rating, in that he has recurring episodes of severe symptoms less than four times a year averaging ten days in duration, but has continuous moderate manifestations. The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1998), has reviewed and considered all of the evidence and material of record in the veteran's claims files. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the veteran’s claim of entitlement to an increased rating, greater then 20 percent, for duodenal ulcer. Accordingly, the Board finds that the criteria for entitlement to an increased rating, greater than 20 percent, for duodenal ulcer are not met. Therefore, the veteran’s claim is denied. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, § 4.114, Diagnostic Code 7305 (1998). ORDER Entitlement to an increased rating, greater than 20 percent, for duodenal ulcer is denied. M. W. GREENSTREET Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1998), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. - 2 -