Citation Nr: 9908333 Decision Date: 03/26/99 Archive Date: 03/31/99 DOCKET NO. 97-06 747A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in White River Junction, Vermont THE ISSUE Entitlement to an increased (compensable) evaluation for Barrett's esophagus. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Steven D. Reiss, Associate Counsel INTRODUCTION The veteran served on active duty from November 1990 to June 1991, including service in the Persian Gulf War. Prior to his period of active duty, he served for more than 10 years in the Army National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 1996 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in White River Junction, Vermont. In that rating decision, the RO granted service connection for Barrett's esophagus and assigned a noncompensable evaluation, effective June 6, 1991. The veteran appealed that determination to the Board. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appeal has been obtained. 2. Although the veteran apparently was not afforded a medical examination at entry into active duty, pre-service private medical evidence indicates that it was then productive of some dysphagia, mild epigastric distress, ulceration and stricture, was well controlled by medication, which resulted in mild impairment of health. 3. Persuasive medical evidence of record establishes that the veteran's preexisting Barrett's esophagus underwent a marked increase in severity beyond its natural progression during his period of active duty. 4. The veteran's Barrett's esophagus currently is productive of gastroesophageal reflux, persistent epigastric distress, dysphagia, strictures and ulceration, requiring periodic mechanical esophageal dilation, resulting in considerable impairment of health. CONCLUSIONS OF LAW 1. The veteran's preexisting Barrett's esophagus was 10 percent disabling at his entry into active duty. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.322(a), 4.7, 4.20, 4.114, Diagnostic Code 7346 (1998). 2. Because the veteran's Barrett's esophagus is currently 30 percent disabling due to in-service aggravation, the criteria for a 20 percent evaluation for Barrett's esophagus have been met. 38 U.S.C.A. §§ 1153, 1155, 5107 (West 1991); 38 C.F.R. §§ 3.306, 3.321, 3.322(a), 4.7, 4.20, 4.114, Diagnostic Code 7346 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSION A. Background A private medical record, dated in February 1988, shows that a radiographic upper gastrointestinal examination revealed that there was no evidence of cricopharyngeal spasm or nasopharyngeal reflux. It disclosed, however, that in the distal one-third of the esophagus, there was a fixed narrowing with overhanging irregular edges, superiorly. There was no hiatal hernia, and reflux could not be elicited. The impression was no evidence of cricopharyngeal spasm and irregular narrowing of the distal esophagus. In addition, the physician indicated that the differential possibilities included Barrett's esophagus with an ulcer; a carcinoma was to be ruled out and an endoscopy was recommended. Three days later, a biopsy was performed and Barrett's esophagus with ulceration and stricture was diagnosed. In addition, the pathologist noted that the tissue biopsy revealed what appeared to be normal gastric epithelium, rather than the metaplasia that he had expected. An April 1988 clinical record reflects that the veteran's Barrett's esophagitis, which was noted to be manifested by ulcers and strictures, was much improved as a result of treating the disorder with Cimetidine (Tagamet). A July 1988 record shows that the veteran was doing well on Cimetidine, and that his Barrett's esophagus was productive of almost no heartburn or dysphagia. Thereafter, in September 1988, a second sample biopsy of tissue removed from the veteran's esophagus revealed that the veteran's esophagitis had improved. The diagnosis was Barrett's esophagus. In October 1989, the veteran was again seen for gastrointestinal complaints. The physician indicated that the veteran had ceased treating his Barrett's esophagus with Cimetidine, and recommended that he resume doing so. In December 1989, tissue samples were again taken, and the diagnosis of Barrett's esophagus was confirmed. In addition, the physician indicated that diagnostic studies revealed that the veteran had severe acute and chronic inflammation that was consistent with the diagnosis. A January 1990 clinical record reflects that the veteran reported that he had had two episodes of dysphagia, but that he denied having heartburn. The examiner noted that the veteran did not usually experience reflux symptoms. The assessment was severe reflux esophagitis. A March 1990 clinical entry indicates that the veteran reported that he "felt great"; no symptomatology attributable to his Barrett's esophagus was reported. Finally, in May 1990, the veteran stated that his Barrett's esophagus had worsened, and complained that it was productive of indigestion and heartburn. The examiner suggested that the veteran try Ranitidine (Zantac) to treat the disorder. The service medical records, dated during the veteran's period of service in Army National Guard, disclose that in a Report of Medical Examination, dated in June 1988, the veteran was diagnosed as having esophagitis, and that the disorder was not considered to be disabling. Although requested by the RO, the claims folder does not contain a service physical examination conducted immediately prior to the veteran's mobilization for service in the Persian Gulf War, and it is unclear whether one was performed. However, an entry dated the day prior to his entrance into active duty reflects that the veteran reported having a history of reflux esophagitis that was well-controlled by Zantac. The examiner opined that the disorder would remain well controlled "as long as he persists in treatment." The service medical records, dated during the veteran's period of active duty, show that an April 1991 Report of Medical History reflects that the veteran reported that he was treating his Barrett's esophagus with Tagamet, which he indicated had been diagnosed approximately two and one-half years earlier. A Report of Medical Examination, conducted that same day, also reflects a diagnosis of Barrett's esophagus. In a May 1991 entry, the examiner reported that the veteran's Barrett's esophagus was being treated with Tagamet and that that medication had not proved effective. He further stated that the veteran had previously treated the disorder with Zantac, which had been effective. In a Report of Medical History, dated that same month, the examiner indicated that the veteran had chronic esophagitis. He explained that the veteran was taking Zantac for esophagus and indigestion problems, and that the disorder existed prior to his active service. In a Report of Medical Examination, also dated in May 1991, the examiner indicated that the veteran had a history of Barrett's esophagus, which he noted had existed prior to service. He further opined that the disorder was not aggravated by service, and that the veteran would continue to treat the disorder upon return to civilian care. In August 1991, VA received the veteran's claim for service connection for Barrett's esophagus. The post-service medical evidence in the claims folder includes an October 1991 VA general examination report, a December 1993 VA gastrointestinal examination report, with addenda dated in January, April and June 1994, a September 1994 medical report from the VA gastroenterologist who conducted the December 1993 examination, a July 1996 VA gastrointestinal examination report, post-service medical records of treatment provided by VA and a medical facility at Plattsburgh Air Force Base (Plattsburgh AFB), dated from November 1992 to March 1994, a transcript of the veteran's testimony at a hearing held before a hearing officer at the RO in September 1994, and statements of the veteran. When examined by VA in October 1991, the veteran provided a history of having Barrett's esophagus, which he stated had existed prior to his period of service. He reported that he had been treated for this disability by a physician at a private hospital for approximately three years. The veteran indicated that he was treating the disorder with Zantac. In addition, the veteran reported that he had had no increase in disability from his Barrett's esophagus. No diagnostic tests were performed with respect to this disorder. The diagnosis was Barrett's esophagus, which existed prior to service and that was not aggravated by service. The post-service VA and Plattsburgh AFB medical records, dated from November 1992 to March 1994, reveal that the veteran was seen on numerous occasions for complaints relating to his Barrett's esophagus. In November 1992, the veteran reported that he was referred to the surgery clinic for treatment of an "apple-core" lesion, which he had complained that he had had since the previous month. The veteran denied experiencing weight loss. The physician stated that the veteran's Barrett's esophagus had been well controlled by hydrochloric acid blockers. The impression of the examiner was significant gastroesophageal reflux and questionable esophageal strictures. The medical records further reflect that in February 1993, the veteran reported that the disorder had worsened during his period of active duty in the Persian Gulf. He also stated that he had occasional dysphagia to solids. The examiner indicated that the veteran's ulcers were well healed, and that upper gastrointestinal studies conducted in October 1992 revealed the existence of distal esophageal strictures. In addition, esophagogastroduodenoscopy (EGD) studies were recommended. In May 1993, an EGD with biopsies was performed. The examiner reported that biopsies of tissue from the distal portion of the esophagus, which consisted of portions of the esophageal mucosa with mild epithilial hyperplasia, disclosed that the adjacent tissue was partly lined by acute inflammatory exudate and necrotic debris that was consistent with an ulcer. In addition, the adjacent cardiac mucosa showed chronic inflammation. There was no evidence of malignancy. Finally, in January 1994, a repeat EGD was performed which revealed that the veteran had grade IV esophagitis with severe strictures. In June 1993, the Board remanded the veteran's claim for service connection for Barrett's esophagus, and instructed the RO to afford the veteran a VA examination in connection with his appeal. In compliance with the Board's request, in December 1993, the veteran was afforded a VA gastrointestinal examination. The physician, the Chief of the Department of Gastroenterology at the VA medical facility in White River Junction, Vermont, indicated that he had reviewed the veteran's claims folder. The physician discussed the history of the veteran's Barrett's esophagus and noted that he had been diagnosed as having the disorder by a private examiner several years earlier. The physician stated that the veteran's Barrett's esophagus was initially manifested by dysphagia and heartburn, and that he was treated with a hydrochloric acid blocker. The examiner further reported that, in February 1993, an endoscopy was performed that disclosed severe esophageal reflux symptoms. An esophageal dilation was recommended but was apparently not performed. In addition, he observed that there had been some discussion about switching the veteran from Tagamet to Zantac, but that that too was not done. The veteran reported that his symptoms increased during the Persian Gulf War and that his Barrett's esophagus had remained symptomatic since that time. He complained that he had heartburn that was postprandial and that, approximately one to two times per week, it was severe. In addition, the veteran reported that he had intermittent dysphagia for solids, especially breads, and that, approximately once per week, he had to voluntarily "gag himself" to unblock his esophagus. He stated that he treated the disorder with Rolaids as well as Tagamet. The physician reported that the veteran weighed 170 pounds. In addition, he commented that, given the veteran's severe esophageal symptomatology, a disturbance of motility was assumed. He explained that, prior diagnostic tests had revealed an actual partial obstruction, as well as a stricture. In addition, he reported that the veteran exhibited reflux disturbance, heartburn, and pain. The diagnoses were Barrett's esophagus, complicated by esophagitis and esophageal stricture, as well as gastroesophageal reflux disease. The examiner reported that both disorders became symptomatic during his service in the National Guard. Finally, he stated that, because the veteran was symptomatic and had not had an upper endoscopy for more than a year, he had scheduled an upper endoscopy with biopsies and dilation for January 1994. In an addendum to the December 1993 report, dated in January 1994, the same examiner reported that an upper endoscopy had revealed severe grade 4 erosive esophagitis as well as severe esophageal strictures with pseudodiverticulum formation. In addition, he stated that the biopsies disclosed that the veteran probably had "a short segment Barrett's esophagus." With regard the second finding, the examiner commented, "in fact, it's a wonder that he can eat solid food to maintain his weight considering the severity of his esophageal disease." He explained that, with some difficulty, he was able to place a guidewire past the stricture and accomplish a slight dilation. The physician indicated that he prescribed a powerful anti-reflux regimen to treat the disorders. In addition, the examiner noted that he planned to perform a repeat dilation and EGD the following month. The physician further commented that the veteran would probably require several such sessions in order to have his esophagus dilated to normal size so that he could take a normal amount of food. In an April 1994 addendum to the December 1993 VA examination report, the same physician reported that a repeat EGD was performed that revealed that the veteran had a "pin-hole" peptic stricture of the distal esophagus. The physician stated that the veteran had now undergone "a total of seven dilations," and the dilation that morning had increased his esophageal diameter to 60 French with the Maloney system. He explained that that was accomplished with a guidewire system and endoscopy. The examiner also reported that he has placed the veteran on Omeprazole, which he opined the veteran would require all his life. In addition, he indicated that he would cease performing dilations to assess whether the veteran's dysphagia recurred. The physician stated that, if the dysphagia recurred, that would indicate that the veteran would require lifelong intermittent esophageal dilation because of cicatricial narrowing of the distal esophagus. Significantly, the examiner stated, It seems likely[,] in retrospect[,] that the time the veteran spent in the Persian Gulf[,] where he was inadequately treated for this disorder[,] led to the severity of his esophageal injury, and [that] if he had cicatric[i]al narrowing, this would, in fact, be due to the duration of the untreated disease, and a direct result of his overseas military experience. The examiner further commented, Regardless of whether or not he has the permanent cicatric[i]al narrowing, the severity alone of his disease and the fact that he required seven dilations to achieve a normal esophageal diameter speaks of the severity of his illness, which once again was due to the fact that he went so long untreated despite trying to seek medical attention both in the Persian Gulf and also at the Plattsburgh Military Hospital after return from the Persian Gulf. I think the reason for this is the fact that both facilities were not equipped with the type of equipment and specialists necessary to treat this disorder. In June 1994, the veteran was again examined by the physician who conducted the December 1993 VA examination. In the June 1994 addendum, the examiner stated that the veteran presented with recurrent intermittent dysphagia for solid foods. The veteran denied having heartburn or any other reflux manifestations, and stated that he had "faithfully" took the Omeprazole. The examiner reported that he again dilated the veteran's esophagus with a Maloney system, indicating that the veteran's dysphagia had recurred. The examiner stated that he instructed the veteran to continue treating the disorder with Omeprazole. The diagnosis was recurrent dysphagia secondary to cicatricial narrowing of the distal esophagus due to severe peptic esophagitis, with an interval dilation performed. In response to a request from the veteran's representative, the same gastroenterologist who performed the December 1993 VA examination prepared a medical report in September 1994 in which he discussed the history of the veteran's Barrett's esophagus as well as the current state of the disorder. In the report, the physician stated that, when he examined the veteran in December 1993, the veteran presented with symptoms of severe dysphagia. In addition, he commented that "it is clear that in the late 1980s he had reflux esophagitis, and had a previous upper endoscopy around 2-4 years ago by [a private physician] that confirmed reflux and also a change in the cell type lining of the esophagus known as Barrett's esophagus." He reported that these symptoms had developed during a time when the veteran was in the National Guard, but stated that, prior to the time he entered active duty during the Persian Gulf War, he had not had dysphagia. The physician added that, while in Saudi Arabia, the veteran developed severe dysphagia, and in February 1993, an esophageal stricture was discovered during an endoscopy at Plattsburgh Military Hospital. He added that "[u]nfortunately, they did not perform further testing or treatment at that time, and he remained undertreated until he saw me in December of that year." The physician added that, since that time, after numerous mechanical dilations and through the use of "an extremely high dose" acid suppression therapy medication, the veteran had "finally" reached a point where his symptoms have dramatically improved. He cautioned, however, that the improvement in the symptomatology could only be maintained if he continued, for life, to treat the disorder with high dose medications and periodic mechanical dilations. The physician explained that the veteran's esophagus remained severely scarred and damaged from acid damage. Significantly, the examiner stated that his review of the veteran's medical records revealed that the veteran had a mild acid problem prior to his period of active duty. He added that there was a marked increase in the severity of his symptomatology, and also an increase in the severity of the damage to his esophagus, subsequent to service. In this regard, the examiner cited to a comparison between the endoscopies that had been performed at the Plattsburgh AFB and at the VA medical facility in White River Junction, Vermont to those performed prior to his Persian Gulf War service. The physician indicated that there were several possibilities that would account for the worsening. He explained that it might be related to emotional stress, which he stated would lead to increased gastric acid secretions. He also suggested that it could be related to the veteran's exposure to one of a number of parasites that he may have acquired in Saudi Arabia and which could have diminished the peristalsis of his esophagus. He stated that that happened on occasion and is extremely difficult, if not impossible, to diagnose and treat. The examiner reported that, in that case, the patient is usually left with an extremely poorly functioning esophagus. At his September 1994 hearing, the veteran testified that his Barrett's esophagus was initially diagnosed by a private examiner in 1988. In addition, he stated that the disorder increased in severity while he was serving in the Persian Gulf because he was unable to continue treating it with Zantac. He also argued that his Barrett's esophagus was aggravated by the psychological stress he experienced during his service in the Persian Gulf. The veteran reported that he began to have gastrointestinal problems during approximately the second month that he was stationed in the Persian Gulf, that he had lost weight due to the disorder, and that, while overseas, he had to stick a finger down his throat in order to swallow. He also testified that he had not received much treatment for his Barrett's esophagus during service. In addition, the veteran reported that he had surgery to "stretch his throat" in 1993. In April 1996, the Board again remanded the veteran's claim for service connection for Barrett's esophagus, and instructed that another VA gastrointestinal examination be conducted. In compliance with the Board's request, in June 1996, the veteran was afforded a VA gastrointestinal examination. In the examination report, the physician indicated that he had extensively reviewed the veteran's claims folder, including the EGD reports maintained at the White River Junction, Vermont VA medical center, and discussed the history of the veteran's Barrett's esophagus. In doing so, he stated that the symptomatology was well controlled prior to service by Ranitidine (Zantac). He added that Ranitidine was not available to the veteran during his service in Saudi Arabia, and that he was instead treated with Cimetidine (Tagamet). The examiner observed that the veteran became "very symptomatic," and initially had increased heartburn. The veteran's Barrett's esophagus was productive of dysphagia, which thereafter worsened, and he was diagnosed as having severe peptic stricture. He was subsequently treated at the White River Junction, Vermont, VA medical center, where dilation was performed. The examiner reported that the veteran periodically undergoes dilation to treat the disorder. The veteran complained of having acid indigestion, occasional abdominal pain and pyrosis if ceased treating his Barrett's esophagus with Omeprazole. He added that this is followed by dysphagia, which occurred even if he neglected to take the Omeprazole for only one day. The examination revealed that the veteran weighed 178 pounds and had no anemia. In addition, the physician estimated that the veteran had occasional or episodic motility. He also reported that the veteran had actual partial obstructions approximately once per year, but that he had experienced it more frequently in the past. The examiner further stated that the veteran did not have heartburn or reflux as long as he treats the disorder with Omeprazole. Finally, the examination disclosed that the vetera did not exhibit pain, but complained of having abdominal discomfort if he ceased taking the Omeprazole. The physician opined that the veteran's gastroesophageal reflux disease that "worsened significantly" during his period of active service in the Persian Gulf and which resulted in peptic stricture formation. He explained that this was due to a combination of "inadequate treatment" and "increased stress." The examiner stated, to treat his gastrointestinal problems, that the veteran would require life-long acid suppression and periodic dilation. In his numerous statements, the veteran acknowledged that his Barrett's esophagus existed prior to active service, but maintained that it was permanently worsened by his period of active duty. He essentially reiterated that his Barrett's esophagus was inadequately treated during the time he served in the Persian Gulf. The veteran specifically attributed the worsening to his inability obtain Zantac to treat the disorder, which he reported was effective in controlling his Barrett's esophagus. Moreover, the veteran did not take issue with the current 30 percent evaluation assigned for his Barrett's esophagus; rather, he challenged the RO determination that his Barrett's esophagus was 30 percent disabling prior to service. In the July 1996 decision on appeal, the RO granted service connection for Barrett's esophagus. The RO then evaluated the disability by analogy to a hiatal hernia and assigned a noncompensable rating under Diagnostic Code 7399-7346. In determining that a noncompensable evaluation was appropriate, the RO observed that the veteran had Barrett's esophagus prior to service and reasoned that regulations required that the rating reflect only the degree of disability over and above the degree of disability that existed at the time of entrance into active duty. The RO concluded that the veteran's Barrett's esophagus was 30 percent disabling at entry into active duty and that it was currently 30 percent disabling, and thus the deduction of the preservice level of disability from the current level disability, (i.e. 30-30) resulted in the noncompensable evaluation. B. Analysis As a preliminary matter, the Board finds that the veteran's claim for a compensable evaluation for his service-connected Barrett's esophagus is plausible and capable of substantiation and is therefore well grounded within the meaning of 38 U.S.C.A. § 5107(a). A claim that a service- connected condition has become more severe is well grounded where the claimant asserts that a higher rating is justified due to an increase in severity. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 631-632 (1992). The Board also is satisfied that all relevant facts have been properly developed and no further assistance to the veteran is required in order to comply with the duty to assist. Id. As the medical evidence cited to above clearly reflects, the veteran's Barrett's esophagus clearly preexisted service. Accordingly, although not explicitly explained by the RO in its decision, the only basis for a grant of service connection for such a condition is on the basis of aggravation of a preexisting disability. See 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. In cases involving aggravation by active service, the rating will reflect only the degree of disability over and above the degree of disability existing at the time of entrance into active service, whether it was noted at entry into active service, or whether it was determined upon the evidence of record to have existed at that time. It is necessary to deduct from the present evaluation the degree, if ascertainable, of the disability existing at the time of entrance into active service, in terms of the rating schedule, except that if the disability is total (100 percent), no deduction will be made. If the degree of disability at the time of entrance into service is not ascertainable in terms of the schedule, no deduction will be made. 38 C.F.R. § 3.322. In the instant case, as there is no specific diagnostic code for evaluation of Barrett's esophagus, the condition is evaluated by analogy to a hiatal hernia under Diagnostic Code 7346. See 38 C.F.R. § 4.20, 4.114. Pursuant to that diagnostic code, a 60 percent evaluation is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A 30 percent evaluation requires evidence of persistently epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent evaluation is assigned for two or more of the symptoms for the 30 percent evaluation of less severity. The Board agrees with the RO's assessment that the veteran's Barrett esophagus is currently 30 percent disabling. The evidence shows that the disorder is manifested persistently recurrent epigastric distress with severe dysphagia; indeed, in the April 1994 addendum to the December 1993 examination report, the physician noted that the veteran has required no less than seven esophageal dilations. Moreover, that physician, as well as the physician who conducted the June 1996 VA gastrointestinal examination, agreed that the veteran would probably require periodical mechanical esophageal dilations throughout his lifetime. In addition, the disorder is productive of pyrosis and reflux, and although not accompanied by substernal or arm or shoulder pain, results in productive of considerable impairment of health. A 60 percent rating for this disorder is not warranted, as the Barrett's esophagus has improved with treatment. The Board notes that the veteran's weight was recorded as 170 pounds in the December 1993 examination report. Thereafter, when examined in June 1996, the examiner indicated that the veteran weighted 178 pounds. Further, he specifically reported that he had no anemia. In addition, despite the thoroughness of the examinations and the number of diagnostic studies performed, there is no evidence of hematemesis. In any event, as noted above, the veteran does not challenge the current 30 percent evaluation. With respect to application of 38 C.F.R. § 3.322, the question remains, however, as to whether the status of the veteran's disability at the time of entrance into service is ascertainable; if so, the extent of such disability; and, given the RO's assignment of zero percent evaluation in this case (and the veteran's arguments against that evaluation), the extent of aggravation of the disability in service. As the evidence above indicates, there is no report of examination at the veteran's entry into active service. However, the record contains medical evidence bearing on the probable severity of the veteran's disability at the time. Here, there is medical evidence showing that the veteran was initially diagnosed as having Barrett's esophagus in February 1988. Private medical records also reveal that the disability was productive of ulcers and strictures, mild heartburn and dysphagia, although the veteran did not experience reflux symptoms. Significantly, the disorder was well controlled by medications; initially by Cimetidine (Tagamet), and thereafter by Ranitidine (Zantac). Moreover, a National Guard medical record prepared in June 1988, reflects that the veteran was noted to have esophagitis that was not considered to be disabling. The service medical records, dated during the veteran's period of active service, disclose that in November 1990, on the day before he entered active duty, he reported that he had a history of reflux esophagitis that was well controlled by Zantac. Moreover, the examiner indicated that the disorder would remain well controlled "as long as he persists in treatment." During service, he was treated with Tagamet; although a May 1991 service physician indicated that that medication had not proved to be effective, in the May 1991 Report of Medical Examination, a service physician indicated that the veteran's Barrett's esophagus existed prior to service and that it was not aggravated by service. The post-service medical evidence from the White River Junction VAMC and the Plattsburgh AFB reveals that subsequent to service, the veteran's Barrett's esophagus was productive of dysphagia, gastroesophageal reflux, pain, distal esophageal strictures and ulcerations. The Board finds that the post-service VA medical evidence (consisting of the December 1993 VA examination report, with the January, April and June 1994 addenda, and the September 1994 report, all prepared by the Chief of the Gastroenterology Department at the White River Junction VAMC; and the June 1996 VA examination report) is most illustrative in demonstrating both the level of disability at entrance into active duty, and the extent to which the veteran's disability increased in severity in service. In this regard, the Board observes that both these physicians clearly reviewed the veteran's entire medical history prior to reaching their medical conclusion. Moreover, in addition to being extremely detailed in assessing the symptomatology of the veteran's disability, both prior to his period of active duty and currently, the first examiner conducted numerous diagnostic tests. In the December 1993 examination report, the physician observed that the veteran's Barrett's esophagus was initially manifested by dysphagia and heartburn, and that he was treated with a hydrochloric acid blocker. The physician further reported that, in February 1993, an endoscopy was performed which disclosed severe esophageal reflux symptoms. He also noted that the veteran reported that he had had intermittent dysphagia for solids, approximately once per week, and that to treat the disorder, he voluntarily gagged himself to unblock his esophagus. The physician stated that the initial examination revealed that the veteran exhibited reflux disturbance, heartburn, and pain. He diagnosed Barrett's esophagus, complicated by esophagitis and esophageal stricture, as well as gastroesophageal reflux disease. The examiner reported that both disorders became symptomatic during his service in the National Guard. In addition, he ordered that a repeat upper endoscopy, which revealed that the veteran had severe grade 4 erosive esophagitis as well as severe esophageal strictures with pseudodiverticulum formation. In addition, he stated biopsies disclosed that the veteran probably had "a short segment Barrett's esophagus," and he commented that "it's a wonder that he can eat solid food to maintain his weight considering the severity of his esophageal disease." In the April 1994 addendum, the examiner noted that the veteran had, by then, undergone seven dilations of his esophagus. Of great significance, the examiner commented that the veteran's Barrett's esophagus was aggravated during his period of active duty, and attributed the worsening to the duration of time that it went untreated. Moreover, in the June 1994 addendum, the physician stated that the veteran had recurrent intermittent dysphagia for solid foods. In addition, although the veteran faithfully took the Omeprazole that he had prescribed to treat the disorder, and indeed denied experiencing heartburn or any other reflux symptoms, the physician indicated that he again was forced to dilate the veteran's esophagus because the dysphagia had recurred. In the September 1994 report, the same gastroenterologist noted that, when he initially examined the veteran in December 1993, he presented with symptoms of severe dysphagia. He noted that the veteran had been diagnosed as having Barrett's esophagus in 1988, but added that, while in Saudi Arabia, the veteran developed severe dysphagia, and in February 1993, an esophageal stricture was discovered during an endoscopy at Plattsburgh Military Hospital. He stated that "[u]nfortunately, they did not perform further testing or treatment at that time, and he remained undertreated until he saw me in December of that year." The physician added that, since that time, after numerous mechanical dilations and through the use of "an extremely high dose" acid suppression therapy medication, the veteran has "finally" reached a point where his symptoms have dramatically improved. He cautioned, however, that the improvement in the symptomatology could only be maintained if he continued, for life, to treat the disorder with high dose medications and periodic mechanical dilations. The physician explained that the veteran's esophagus remained severely scarred and damaged from acid damage. Significantly, the examiner stated that his review of the veteran's medical records revealed that the veteran had a mild acid problem prior to his period of active duty. He added that there was a marked increase in the severity of his symptomatology, since his period of active, which he attributed to service. Finally, in the June 1996 examination report, the physician indicated that he had extensively reviewed the veteran's claims folder stated that the symptomatology was well controlled prior to service by Ranitidine (Zantac). He added that Ranitidine was not available to the veteran during his service in Saudi Arabia, and that he was instead treated with Cimetidine (Tagamet). The examiner observed that the veteran became "very symptomatic," and initially had increased heartburn. In addition, he stated that he veteran's Barrett's esophagus was productive of dysphagia, which thereafter worsened, and he was diagnosed as having severe peptic stricture. He was subsequently treated at the White River Junction, Vermont, VA medical center, where multiple, periodic dilations were performed. Of particular note, the physician opined that the veteran's gastroesophageal reflux disease that worsened significantly during his period of active service in the Persian Gulf that resulted in peptic stricture formation; this examiner also attributed the aggravation of his Barrett's esophagus to service. Based on its application of 38 C.F.R. § 3.322, the RO assigned a compensable evaluation for Barretts's esophagus (under Diagnostic Code 7399-7346) based on its determination that the condition was 30 percent disabling prior to entry into active service and currently. While the medical evidence cited to above confirms the current assessment that the condition is 30 percent disabling, that evidence points to a different conclusion as regards the degree of the veteran's disability at entry into service. The Board finds that the disability picture for the veteran's Barrett's esophagus prior to his period of active duty most closely approximates the criteria for a 10 percent rating under Diagnostic Code 7346. In reaching this determination, the Board points observes that, although prior to his period of active service the disorder was generally well controlled, initially by Tagamet and subsequently by Zantac, it was productive of some dysphagia and periodic, mild epigastric distress. Moreover, ulcerations and strictures were noted. As noted above, the medical opinions offered by the VA examiners based on their physical examinations and the result of the diagnostic tests shows that the veteran's Barrett's esophagus underwent a marked increase in disability during his period of active duty. Thus, applying the provisions of 38 C.F.R. § 3.322, the current evaluation for the veteran's service-connected Barrett's esophagus should be 20 percent, based on deduction of the preservice level of disability (10 percent) from the current level of disability (30 percent). ORDER Subject to the law and regulations governing payment of monetary benefits, a 20 percent rating for Barrett's esophagus is granted. JACQUELINE E. MONROE Member, Board of Veterans' Appeals Department of Veterans Affairs