Citation Nr: 1300385 Decision Date: 01/04/13 Archive Date: 01/11/13 DOCKET NO. 05-21 617 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to a rating in excess of 20 percent for a gastric ulcer. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran served on active duty from October 1963 to December 1965. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2004 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi, in which the RO continued a 20 percent rating for postoperative gastric ulcer with gastritis. In February 2009, the Board remanded the claim for an increased rating for a post-operative gastric ulcer with gastritis to the RO via the Appeals Management Center (AMC) in Washington, DC, for further development. In an October 2010 decision, the Board denied an increased rating. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a June 2011 Order, the Court granted a Joint Motion by the parties to vacate and remand the October 2010 Board decision and returned the matter to the Board for further proceedings. In February 2012, the claim was again remanded to the RO via the AMC for further development. After completing additional development, the AMC continued to deny the claim (as reflected in a November 2012 supplemental SOC (SSOC)), and returned this matter to the Board for further appellate consideration. The Board has reviewed the contents of the Veteran's Virtual VA file and found that it contains additional medical evidence that has been considered by the AMC in the November 2012 SSOC. Therefore, the Board's consideration of this evidence will not result in prejudice to the Veteran. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim on appeal has been accomplished. 2. Resolving any reasonable doubt in his favor, during the period from October 1, 2003 to January 21, 2010, the Veteran's service-connected gastric ulcer disability was moderately severe, manifested by anemia and weight loss. 3. Since January 21, 2010, the Veteran's service-connected gastric ulcer disability has been no worse than moderate and has not been manifested by anemia and weight loss or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times per year. CONCLUSIONS OF LAW 1. During the period from October 1, 2003 to January 21, 2010, the criteria for an increased rating of 40 percent, but no greater, for the service-connected gastric ulcer disability have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.21, 4.114, Diagnostic Code 7304 (2012). 2. Since January 21, 2010, the criteria for a rating in excess of 20 percent for the service-connected gastric ulcer disability have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.21, 4.114, Diagnostic Code 7304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.") and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. See 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction). The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. Duty to Notify and Assist The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the Court have been fulfilled. In this case, the Veteran's claim for an increased rating for his service-connected gastric ulcer was received in February 2004. Thereafter, he was provided notice of what evidence was required to substantiate his claim for an increased rating, and of his and VA's respective duties for obtaining evidence in correspondence dated in February 2004. Thereafter, the claim was reviewed and the May 2004 rating decision was issued. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006), Mayfield v. Nicholson (Mayfield III), 499 F.3d 1317 (Fed. Cir. 2007). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court found that the VCAA notice requirements applied to all elements of a claim. Notice as to this matter was provided in March 2006. Although the March 2006 letter was not issued prior to the decision on appeal, the Veteran's claim was readjudicated in the October 2006, February 2010 and November 2012 SSOCs. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). The Veteran has been made aware of the information and evidence necessary to substantiate his claim and has been provided opportunities to submit such evidence. A review of the claims file and Virtual VA e-folder shows that VA has conducted reasonable efforts to assist him in obtaining evidence necessary to substantiate his claim during the course of this appeal. His VA and private treatment records have been obtained and associated with his claims file. The Veteran was also provided with VA examinations to evaluate his service-connected disability in May 2004, May 2006, January 2010, and April 2012. As noted above, this case was remanded February 2012 so that additional VA treatment records could be obtained and so that the Veteran could be provided a VA examination to evaluate his gastric ulcer disability. The AMC obtained the records requested in the Board's February 2012 remand directives and the Veteran underwent a VA examination in April 2012. There substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In June 2006, the RO requested the Veteran's records from the Social Security Administration (SSA). In a July 2006 response, the SSA indicated that the requested medical records could not be furnished because after an exhaustive and comprehensive search, the folder could not be located. The October 2006 SSOC advised the Veteran that the SSA had responded that there was no evidence of any medical claims/record or SSA disability found. Under these circumstances, the Board finds that VA has fulfilled its duty to attempt to obtain the SSA records, and that no further action in this regard is required. The Veteran has not identified any additional, relevant evidence that has not been requested or obtained. The Veteran has been notified of the evidence and information necessary to substantiate his claim, and he has been notified of VA's efforts to assist him. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating his claim. The Merits of the Claim Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which assigns ratings based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). For reasons which will be discussed below, the Board finds that assignment of staged ratings is appropriate in this case. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In a February 1967 rating decision, the RO granted service connection for a gastric ulcer and assigned an initial 10 percent rating, pursuant to Diagnostic Code 7304. Following vagotomy and pyloroplasty in 1969, the RO granted an increased 20 percent rating for postoperative gastric ulcer with gastritis in a July 1970 rating decision, pursuant to Diagnostic Code 7304. In August 2003, the Veteran underwent surgery for his service-connected disability. In an October 2003 rating decision, the RO granted a temporary 100 percent rating effective August 20, 2003 (the date of his surgery) based on surgical or other treatment necessitating convalescence, pursuant to 38 C.F.R. § 4.30. A 20 percent rating was assigned effective October 1, 2003. In February 2004 the Veteran filed his current claim for an increased rating. In the May 2004 rating decision, the RO continued the 20 percent rating pursuant to Diagnostic Code 7304. The severity of a digestive system disability is ascertained, for VA rating purposes, by application of the criteria set forth in VA's Schedule for Rating Disabilities at 38 C.F.R. § 4.114. Ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. 38 C.F.R. § 4.114. A single evaluation will be assigned under the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. Id. Under 38 C.F.R. § 4.114, gastric ulcers (Diagnostic Code 7304) and duodenal ulcers (Diagnostic Code 7305) are evaluated pursuant to the same rating criteria. A rating of 60 percent is warranted for severe symptoms with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. A 40 percent rating is warranted for symptoms that are moderately severe, that is, less than severe but with impairment of health manifested by anemia and with weight loss; or for recurrent incapacitating episodes averaging 10 days or more in duration at least four times per year. A 20 percent rating is warranted for symptoms that are moderate, with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous moderate manifestations. A 10 percent rating is warranted for symptomatology that is mild with recurring symptoms once or twice yearly. 38 C.F.R. § 4.114, Diagnostic Codes 7304, 7305. The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of the inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. Layno v. Brown, 6 Vet. App. 465 (1994). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service-connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). VA treatment records reflect ongoing gastrointestinal complaints and treatment, with findings of gastroesophageal reflux disease (GERD), gastritis, and peptic ulcer disease since the Veteran's August 2003 surgery. In July 2003, the Veteran had an esophagogastroduodenoscopy (EGD) to evaluate a hiatal hernia and dyspepsia. The impression was normal appearing hypopharynx, esophagus, gastroesophageal junction, and duodenum. Testing revealed chronic gastritis of the stomach. An August 2003 EGD revealed a normal hypopharynx, esophagus, and gastroesophageal junction. There was a moderate hiatal hernia, chronic gastritis of the stomach, and evidence of a previous pyloroplasty. In August 2003, the Veteran underwent laparoscopic Nissen fundoplication for GERD. In November 2003, he reported feeling "run down" and stated that he did not get his iron tablets refilled as he lost his prescription. On review of systems, he denied nausea, vomiting, weight changes, early satiety, diarrhea, and abdominal swelling or pain. His active problems listed included GERD/other specified disorders of the stomach and other specified gastritis and iron deficiency anemia. The Veteran reported that he was no longer taking rabeprazole and ranitidine for GERD since two weeks after his surgery. In January 2004, the Veteran reported that he was not taking medicines for GERD but was experiencing no symptoms. On review of systems he again denied nausea, vomiting, weight changes, early satiety, diarrhea, and abdominal swelling or pain. The Veteran was instructed to continue taking iron supplements for anemia. During treatment for neck pain later that month, the Veteran described his GERD as "resolved." In February 2004, the Veteran gave a long history of GERD refractory to medical therapy. It was noted that this had initially been managed 30 years earlier with a truncal vagotomy and drainage but, because of recurrent symptoms, he underwent Nissen fundoplication in August 2003. He reported that he was doing well since this surgery except for a 20 pound weight loss. He also described some diarrhea and cramping after meals; however, upon further questioning, he stated that this diarrhea and cramping had been going on for many years and did not worsen after surgery. The physician noted that the Veteran was on colchicines, which might be contributing to his diarrhea. He added that the Veteran's symptoms of diarrhea and cramping were more consistent with an irritable bowel syndrome-type picture than anything related to his esophageal wrap. In April 2004, the Veteran was seen by a dietician due to complaints of diarrhea and a history of hypoglycemia. He was instructed in an anti-dumping meal plan. While the Veteran expressed concern over his weight of 175.6 pounds, the dietician noted that his weight was within the normal range for his height and weight gain was not recommended. In May 2004, the Veteran presented with complaints including a poor appetite and loose stools. He described a persistently decreased appetite since his August 2003 surgery. However, the physician noted that the Veteran had been taking three iron pills per day since January for iron deficiency anemia, and his last ferritin was normal at 26. The physician stated that iron supplementation might be part of the Veteran's appetite problem, and so it was held to see the effect on his appetite. The Veteran was afforded a VA examination to evaluate his service-connected disability in May 2004. He reported undergoing surgery for chronic dyspepsia in August 2003, after which he stated he improved symptomatically but lost about 25 pounds and became somewhat anemic. He stated that his anemia was being treated with iron supplementation with improvement and he denied taking any medications specifically for his stomach condition. He denied vomiting, hematemesis, and melena, but complained of abdominal bloating soon after eating, occasional diarrhea, and a poor appetite. On examination, the Veteran was well-nourished and weighed 171 pounds. The abdomen was soft and nontender with no mass or organomegaly. He had well-healed healthy scars from his prior abdominal surgery. The diagnosis was gastric ulcer treated with gastrectomy in the past with a second surgery for his stomach condition, since which he had had mild anemia and weight loss for which he was currently being treated. Upper GI from the date of examination revealed status post gastroplasty with sliding hiatal hernia and mild gastroesophageal reflux. A VA treatment record from later in May 2004 reflects diagnoses including GERD status post fundoplication and iron-deficiency anemia. The gastroenterologist noted that the Veteran complained of diarrhea approximately 15 to 20 minutes after each meal, loss of appetite, and a weight loss of approximately 20 pounds in the six months since his surgery. He added that the Veteran was found to have iron-deficiency anemia with good improvement in hematocrit on iron replacement. The Veteran denied symptoms of reflux disease in the form of regurgitation or heartburn, but described occasional epigastric discomfort or pain. He denied hematemesis, hematochezia, and melena. The assessment was symptoms of abdominal discomfort and diarrhea, starting immediately after taking food, probably suggesting gastroparesis which had been aggravated after the surgery. The gastroenterologist also included an assessment of weight loss and anemia, stating that he did not have any explanation for the weight loss and, if it continued, the Veteran may need a CT scan of the abdomen. A July 2004 record of follow-up treatment for anemia indicates that the Veteran's laboratory reports from earlier that month revealed normal hemoglobin and hematocrit. On review of systems the Veteran denied nausea, vomiting, weight changes, early satiety, diarrhea, and abdominal swelling or pain. The Veteran underwent an EGD in July 2004 to assess his weight loss, iron deficiency anemia, dyspepsia, and history of Nissen's fundoplication one year earlier. The impression was normal appearing hypopharynx, esophagus, stomach, and duodenum, with moderately deformed pylorus. It was noted that the fundoplication was intact. The impression following colonoscopy the same day was a single small sessile smooth polyp in the cecum, a single small sessile smooth polyp in the ascending colon, and a small anal skin tag on retroflexion, but an otherwise normal colonoscopy. In September 2004, the Veteran presented for follow-up of GERD. His weight was noted to be stable. Regarding anemia, it was noted that his hemoglobin, hematocrit, and ferritin were normal in July 2004. In March 2005, he returned for follow-up on anemia, when it was again noted that it his hemoglobin, hematocrit and ferritin were normal in July 2004. Laboratory studies were described as pending. In a June 2005 statement submitted with his substantive appeal, the Veteran described heartburn and gas when lying down at night and stated that he only ate once a day but had diarrhea within 30 minutes after eating. He described his weight as stable, stating that he had no appetite. During VA treatment for GERD the following month, he reported some dysphagia with occasional vomiting while sleeping. A July 2005 EGD revealed that the Nissen fundoplication seemed to have broken down and the lower esophageal sphincter was wide open. The EGD also showed a probable moderate 4 cm. hiatal hernia. The stomach, pylorus, and duodenum appeared normal. A September 2005 record of treatment regarding the right shoulder reflects that the Veteran's weight was stable. As regards his anemia, it was noted that his hemoglobin and hematocrit were normal in August 2005 and July 2004. In December 2005, the Veteran had another EGD to evaluate dyspepsia and GERD symptoms. This study revealed nonerosive gastritis of the antrum and the fundoplication was described as appearing loose at best. The assessment following treatment in January 2006 included anemia, and it was noted that laboratory studies were pending. The Veteran's GERD medication, omeprazole, was increased. During treatment for esophageal candida in April 2006, the Veteran denied nausea or vomiting and stated that his reflux had stopped on increased medicine. A record of treatment from later that month reflects that the Veteran denied weight gain or loss. On EGD in April 2006, the stomach, pylorus, and duodenum appeared normal. The Veteran underwent another VA examination to evaluate his disability in May 2006. He described problems with reflux and abdominal pain over the last year. He added that he had been having recurrent fungal infections of the esophagus due to his stomach condition per his gastroenterologist. He denied vomiting, hematemesis, or melena, but reported coughing up a small amount of blood every morning. He then reported vomiting. An upper GI study revealed a hiatal hernia with associated gastroesophageal reflux. The diagnosis was postoperative gastric ulcers with gastritis, GERD with hiatal hernia. During follow-up treatment in July 2006 the Veteran stated that he was doing fine and denied any problems or concerns. He denied weight change and the impression following examination included reflux, stable on omeprazole. A September 2006 EGD revealed a marked sliding hiatal hernia. An EGD from later that month again showed a hiatal hernia. The stomach, pylorus, and duodenum were described as normal appearing. The stomach, pylorus, and duodenum were again noted to be normal appearing following a March 2007 EGD. VA treatment records from January, July, and November 2007 included an assessment of anemia. On each date, it was noted that laboratory studies were pending. A March 2008 VA treatment record notes that the Veteran had chronic anemia presumed to be due to iron deficiency and was on ferrous sulfate tablets. In April 2008, the Veteran presented for treatment with complaints of a six to eight month history of diarrhea with an inability to keep anything down. He reported diarrhea immediately after eating and, so, stated he was not eating very much. Weight loss was noted on the review of systems. The assessment included diarrhea with weight loss, anemia, and GERD. The Veteran requested to purchase iron over the counter, and he was instructed to continue as prescribed. A July 2008 colonoscopy revealed diverticulosis and a single small polyp in the descending colon. A January 2009 VA treatment record reflects that the Veteran described many symptoms of dumping when eating and drinking. He reported that he had not been able to tolerate many solid foods due to poor tolerance, thus, losing weight. The dietitian noted that the Veteran's anemia was beginning to resolve with the addition of ferrous sulfate, and stated that this supplementation was necessary as his diet would not provide adequate iron. The Veteran's GERD was described as stable during VA treatment in December 2009. The Veteran underwent VA examination in January 2010. He denied incapacitation in the past year and stated he had not been prescribed bedrest and had no impediments to doing his activities of daily living. The Veteran denied nausea, vomiting, and hematemesis, but described diarrhea since 2003 and stated that he had watery stools 10 minutes after eating or drinking anything. He reported that his problem had been worse in 2005 and 2006 when he was on Ensure. He denied constipation but described periumbilical cramps, colic without distention, and pain when getting ready to stool. He denied melanotic stools or circulation collapse after a meal. He stated that his condition did not affect his full-time employment at the VA Medical Center (VAMC); although he reported missing at least 14 days of work in the past year because of diarrhea. He described his weight as stable. The Veteran did report epigastric burning radiating substernally without pain and occurring every night for one hour. He denied nausea, vomiting, hematemeis, and melanotic stool. On examination, the Veteran was described as well-developed and well-nourished with a weight of 176 pounds. He denied a change in his weight and noted that he was not wearing his knee and ankle brace, which would probably add six pounds to his weight. He denied a change in his weight in the past year. Hemoglobin was 15.2, hematocrit was 44.8 and iron studies were normal. An upper GI study revealed prior gastroesophageal surgeries, a small hiatal hernia, and no evidence of peptic ulceration or obstruction. The diagnoses following examination were status post partial gastrectomy with current upper GI study showing small hiatal hernia without any peptic ulceration or anemia. The physician noted that the Veteran had stable weight with a subjective complaint of diarrhea. After review of the claims file, the physician stated that the Veteran seemed to have reflux symptoms which could be one of the byproducts of his gastric ulcer, but he had no evidence of anemia nor did he have any significant weight loss, melanotic stools, vomiting, or nausea. The physician noted that the Veteran did report some diarrhea since 2004, for which he was prescribed loperamide, which appeared to be effective; noting that the Veteran only used one tablet three times a week instead of the prescribed dosage of one tablet three times a day, as needed. A May 2010 VA treatment record reflects that the Veteran complained of worsening reflux with more gas and nausea. He stated that he was still only eating one meal a day. He denied any vomiting, including vomiting of blood. The impression was GERD and gastritis. The Veteran underwent EGD in June 2010 to evaluate GERD refractory to proton-pump inhibitor. A biopsy from the antrum showed mild chronic gastritis with no helicobacter identified and a biopsy from the esophagus showed squamous mucosa with active inflammatory changes compatible with mild reflux esophagitis. In July 2010, the Veteran presented to the general surgery clinic for severe symptoms of burning after eating and pain in his abdomen. He stated that he had to sit up at night to avoid vomiting but still had episodes of vomiting. He was referred for to the general surgery clinic for possible Nissen revision. Findings on an August 2010 upper GI series included hiatal hernia with reflux and findings suggesting inflammatory changes in the antrum and duodenal bulb. An August 2010 note reflects that the Veteran had been seen for complaints of reflux, nausea and vomiting. He reported that his symptoms were controlled relatively well with medication. In September 2010, the Veteran was seen in the gastroenterology clinic for complaints of reflux symptoms, abdominal pain, and diarrhea. It was noted that a June 2010 EGD revealed a slipped wrap, but the general surgery clinic decided against a Nissen revision. The Veteran described his appetite as fair, and it was noted that his weight had been fairly stable during the last year until two months earlier, when he had lost about 10 pounds. The assessment was GERD, diarrhea, abdominal pain, and history of peptic ulcer disease status post partial gastrectomy. A December 2010 treatment record reflects that the Veteran was being afforded an EGD and colonoscopy for long-standing watery diarrhea. He denied any weight loss or appetite loss. This December 2010 EGD revealed a hiatal hernia, erosive gastritis in the antrum and body of the stomach, and a slipped Nissen's fundoplication. A colonoscopy from the same day noted findings including mild diverticulosis in the sigmoid colon. Another December 2010 treatment record includes an impression of anemia. The Veteran was encouraged to drink Ensure. He was noted to be overweight at 182.6 pounds, but his weight was described as stable. During VA treatment in March 2011, the Veteran reported reflux symptoms, stating that he only ate once a day because of his symptoms. He stated that his symptoms were not as bad as they had been since he started taking prescribed medication before bedtime, as he had stopped waking up choking. He described diarrheal stool soon after eating or drinking. The impression included GERD and history of partial gastrectomy/diarrhea. The impression following EGD in May 2011 included erythema and congestion in the antrum and stomach body compatible with gastritis and a medium hiatal hernia. The impression following colonoscopy from the same date included normal mucosa in the whole colon with a polyp in the transverse colon, a polyp in the sigmoid colon, and grade 1 internal hemorrhoids. A biopsy from the gastric antrum/body revealed patchy mild chronic gastritis. A biopsy from the esophagus revealed no significant pathologic changes. A biopsy from the transverse colon revealed tubular adenoma. An EGD the following month included findings of a diaphragmatic hiatus, a paraesophageal hernia, and moderately erythematous mucosa in the antrum. A June 2011 treatment record reflects that the Veteran denied weight change and included an impression of anemia. This record indicates that the Veteran was overweight at 173.6 pounds. A July 2011 barium esophagram was unremarkable, with normal appearing esophageal mucosa and no stricture, obstruction, or mass and no gastroesophageal reflux identified. In August 2011, the Veteran described symptoms of reflux and reported eating only once a day because of his symptoms. He reported stool urgency after eating or drinking anything. He denied dysphagia, but reported gas, diarrhea, and abdominal pain. The impression included history of Nissen and information regarding an anti-dumping diet was given. An October 2011 EGD revealed mildly erythematous mucosa in the antrum, a diaphragmatic hiatus, and a hiatus hernia. There was no gastric erosion. Similar findings were noted on EGD the following month. The November 2011 EGD specifically noted no evidence of erosion or ulcers in the stomach. A December 2011 EGD again revealed a hiatus hernia. A December 2011 treatment record reflects that the Veteran again denied weight change and, as in June 2011, includes an impression of anemia. The Veteran was again described as overweight at 178.8 pounds. The Veteran was most recently afforded a VA examination in April 2012. The examiner noted that the Veteran had a gastric ulcer diagnosed in August 1970 and esophageal candidiasis diagnosed in April 2006. The Veteran reported increased epigastric burning and a choking sensation occurring at night for the past month. He had been taking pantoprazole which worked to control his reflux symptoms and abdominal cramping sensation until the last month, when it just seemed to stop working. He had been started on ranitidine one week earlier and he reported that his night time symptoms had already decreased from this medication. The Veteran stated that he continued to have diarrhea 10 minutes after eating. He reported that he had been prescribed loperamide in the past and was currently prescribed an anti-dumping diet. He reported periumbilical cramping from five minutes to two hours after eating which resolved after having a bowel movement. He denied hematemesis, nausea, and emesis. He stated that he had not been prescribed bedrest for a stomach condition within the last five years. The examiner noted that the Veteran had esophageal candidiasis which was associated with daily prednisone use for rheumatoid arthritis. The examiner noted that the Veteran took continuous medication for his gastrointestinal condition, specifically, as mentioned earlier, ranitidine and pantoprazole. She indicated that, as a result of his stomach condition, the Veteran experienced recurring episodes of symptoms which were not severe four or more times per year, with each episode lasting less than one day. She also noted that he experienced periodic abdominal pain at least monthly which was only partially relieved by standard ulcer therapy. Although she did not indicate that the Veteran experienced nausea, the examiner did check the box reflecting that he had two episodes of nausea per year. She reported that the Veteran did not have incapacitating episodes due to signs or symptoms of any stomach condition. She acknowledged that he had scars related to the treatment of his stomach condition, but noted that none of the scars were painful and/or unstable and the total area of all related scars was not greater than 39 square cm. (6 square inches). The examiner noted that a December 2011 upper endoscopy revealed a hiatal hernia, a July 2011 esophagram was unremarkable, and the esophagus was unremarkable on CT scan in July 2011. She noted that a February 2012 CBC revealed hemoglobin of 14 and hematocrit of 40.2. She opined that the Veteran's stomach condition did not impact his ability to work. The diagnoses following examination included service-connected postoperative gastric ulcers with gastritis, partially controlled with medications, mild functional limitations, no objective findings of gastritis or ulcer. Specifically, she indicated that the July 2011 barium esophagram, the July 2011 CT scan, and the December 2011 EGD did not show objective findings of gastritis or an ulcer. The diagnoses also included non-service connected esophageal candidiasis associated with daily prednisone use for rheumatoid arthritis, resolved. She noted that this was not incurred in or caused by postoperative gastric ulcers with gastritis. The examiner noted that the Veteran gave a history of iron deficiency anemia and had been prescribed iron in the past, although he stated that he stopped taking this over two years ago, despite the fact that it continued to appear on his medication list. She indicated that his hemoglobin was normal and, while his hematocrit showed a variation, this was not clinically significant, as it was less than two standard deviations from the normative value and was less likely than not caused by an ulcer condition as the Veteran did not have active ulcers or gastritis. Rather, she stated that the Veteran had non-service connected diverticulosis which was at least as likely as not the cause of his mild decrease in hematocrit. She added that diverticulosis is a condition that is incurred naturally by aging and was not incurred in or caused by his history of gastric ulcers, gastritis, or Nissen fundoplication. A VA treatment record from April 2012, five days after his VA examination, reflects that the Veteran called to report that his medicine was working and he rarely had stomach problems. He stated that he continued to eat once a day. From October 1, 2003 to January 21, 2010 Considering the pertinent evidence of record in light of the law, and resolving all reasonable doubt in favor of the Veteran, the Board finds that an increased, 40 percent rating is warranted from October 1, 2003 until January 21, 2010. The evidence of record demonstrates that the Veteran's gastrointestinal disability has been manifested by anemia and weight loss during this period. Indeed, in the June 2011 Joint Motion, the parties noted that the record revealed diagnoses of or treatment for anemia between January 2004 and March 2005 and from March to July 2008. Joint Motion at pp. 5-6. The parties indicated that, while the Veteran's anemia was described as "beginning to resolve" in January 2009, it was noted that his recommended daily food intake would not provide enough iron to combat the deficiency. Joint Motion at p. 6. The Veteran's VA medication list reflects that he was prescribed ferrous sulfate in June 2003 for iron supplementation. This prescription was discontinued in May 2004; however, on VA examination the following day, the Veteran reported that his anemia was being treated with iron supplementation with improvement. The diagnoses following treatment later that month included iron-deficiency anemia. While the Veteran was noted to have normal hemoglobin and hematocrit on follow-up for anemia in July 2004, and a September 2004 treatment record again noted these normal findings, he nevertheless returned for follow-up of anemia in March 2005. This March 2005 treatment record again noted the normal lab findings from July 2004. The Board has considered whether the Veteran's anemia may be considered to have resolved based on the July 2004 lab findings; however, despite the normal July 2004 findings, review of the actual results of testing from March 2005 through December 2009 reveal findings of low red blood cell count (RBC), hemoglobin (HGB), and/or hematocrit (HCT). According to the Merck Manual, the diagnostic criterion for anemia in men is HGB less than 14 g/dL, hematocrit less than 42%, or RBC less than 4.5 million/ L. See Merck, The Merck Manuals Online Medical Library, Hematology and Oncology, Approach to the Patient with Anemia, (Online Ed.), http://www.merckmanuals.com/professional/hematology_and_oncology/approach_to_the_patient_with_anemia/evaluation_of_anemia.html?qt=anemia&alt=sh. Indeed, all three levels, RBC, HGB, and HCT, were low in January, February, March, and November 2007 and May 2008. Additionally, the Veteran's VA medication list reflects that he was again prescribed ferrous sulfate in December 2007. Moreover, the Veteran's anemia was described as chronic during VA treatment in March 2008, and he was instructed to purchase iron over the counter and continue taking as prescribed. The January 2009 treatment record indicates that Veteran's anemia was beginning to resolve, but the dietitian noted that iron supplementation was necessary because adequate iron would not be provided via the Veteran's diet. In light of the foregoing, and resolving any reasonable doubt in the Veteran's favor, the Board finds that anemia has been demonstrated during the period in question. Additionally, the Veteran has reported, and the record reflects, significant weight loss following his August 2003 surgery. The Veteran weighed 194 pounds on the date of admission for surgery and he subsequently lost weight to a low of 169 pounds in June 2004. The Veteran denied weight loss on review of systems on numerous occasions during the period in question and his weight was described as stable during VA treatment in September 2004 and September 2005. The Veteran himself described his weight as stable in a June 2005 statement; however in his statement, the Veteran also reported that he ate only once a day and had no appetite, suggesting that his weight stability was due to the fact that he had limited eating to once a day. An April 2008 treatment record does include an assessment of diarrhea with weight loss. The Veteran's recorded weights during the period indicate that while his weight increased after his initial loss, there was some variation, with continued periods of weight loss - e.g., a seven pound weight loss from April to May 2007; a 10 pound weight loss from March to April 2008; and a 10 pound weight loss from May to July 2008. Sustained improvement following his initial 25 pound weight loss was not shown during this period. The Board is resolving any reasonable doubt regarding the question of weight loss during this period in the Veteran's favor. In light of the evidence of anemia and weight loss, and considering the reports of discomfort and diarrhea, and resolving any reasonable doubt in the Veteran's favor, the Board finds that the Veteran's service-connected gastric ulcer disability more nearly approximates moderately severe disability during the period in question and, thus, a 40 percent rating is warranted. It was factually ascertainable that there had been an increase in the Veteran's service-connected gastric ulcer disability within one year of his February 2004 claim for an increased rating. Accordingly, the increased, 40 percent rating is warranted from October 1, 2003, the date of termination of his temporary total rating. See 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). However, a rating in excess of 40 percent is not warranted during this period. The evidence does not demonstrate a severe ulcer disability as contemplated in a 60 percent rating pursuant to Diagnostic Code 7304. The evidence does not reflect periodic vomiting or recurrent hematemesis or melena during the period in question. Rather the Veteran denied hematemesis and melena on VA examination in May 2004 and during VA treatment later that month. While during his May 2006 VA examination, the Veteran reported coughing up a small amount of blood every morning, he denied hematemesis during the same examination. The Veteran has periodically reported vomiting; for example, during VA treatment in July 2005, he reported occasional vomiting while sleeping. However, on VA examination in May 2006, he also denied vomiting. He has repeatedly denied vomiting in other VA treatment records and on VA examination in May 2004. Thus, neither periodic vomiting nor recurrent hematemesis or melena has been demonstrated. A rating in excess of 40 percent under this diagnostic code is not therefore warranted. 38 C.F.R. § 4.114, Diagnostic Code 7304. The Board has considered entitlement to an increased rating pursuant to Diagnostic Code 7307, evaluating hypertrophic gastritis; however, there is no evidence of chronic gastritis with severe hemorrhages or large ulcerated or eroded areas as required for a higher, 60 percent, rating pursuant to this diagnostic code. Rather, the stomach was found to be normal appearing on July 2005, April and September 2006, and March 2007 EGDs. Further, a December 2005 EGD specifically revealed nonerosive gastritis. As the evidence during the period in question does not reflect gastritis with severe hemorrhages or large ulcerated or eroded areas, a rating in excess of 40 percent under this diagnostic code is not warranted. 38 C.F.R. § 4.114, Diagnostic Code 7307. Similarly, an increased rating is not warranted pursuant to Diagnostic Code 7346, evaluating hiatal hernia. The evidence does not reflect symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health, as required for a 60 percent rating. Rather, as discussed above, the evidence during this period does not indicate hematemesis or melena. Moreover, the Veteran himself reported in January 2004 that he was experiencing no symptoms of GERD and, later that month, described his GERD as resolved. The following month he stated that, since his August 2003 surgery, he was doing well other than his weight loss. A May 2004 upper GI study revealed only mild gastroesophageal reflux. While the Veteran described occasional epigastric discomfort or pain during VA treatment in May 2004, he denied symptoms of reflux or heartburn. Further, while he complained of heartburn when lying down at night in June 2005 and reported some dysphagia during VA treatment in July 2005, the Veteran stated in April 2006 that his reflux had stopped on increased medicine. The Veteran himself stated that he was doing "fine" during VA treatment in July 2006, and his reflux was described as stable on that date and during VA treatment in December 2009. The Veteran's disability has not been manifested by symptom combinations productive of severe impairment of health, and a rating in excess of 40 percent under this diagnostic code is not warranted. 38 C.F.R. § 4.114, Diagnostic Code 7304. With resolution of all reasonable doubt in the Veteran's favor, a 40 percent rating, but no greater, for the service-connected gastric ulcer is warranted from October 1, 2003 until January 21, 2010. Since January 21, 2010 The January 21, 2010 VA examination is the first medical evidence in which a physician clearly stated that the Veteran was not anemic. Hemoglobin, hematocrit, and iron studies were normal on the date of that examination and the examiner, who reviewed the claims file, stated that the Veteran had no evidence of anemia. Most recently, the April 2012 VA examiner considered the Veteran's history of iron deficiency anemia, but indicated that his hemoglobin was normal. While she acknowledged that his hematocrit showed a variation, she found that such variation was not clinically significant, as it was less than two standard deviations from the normative value. Moreover, she stated that such deviation was less likely than not due to his service-connected ulcer condition; rather, she attributed such mild decrease in hematocrit to non-service connected diverticulosis. These VA examination reports indicate that the service-connected gastric ulcer disability was not manifested by anemia during the period in question. In reaching the above conclusion, the Board has considered that VA treatment records dated in June and December 2010, and June and December 2011 include assessments of anemia, with laboratory studies pending; however, review of the actual lab tests during the period in question reveal normal RBC, HGB, and HCT in May 2010 according to the Merck Manual. While hematocrit was low on several occasions during the period in question, several of these findings were also less than two standard deviations from the normative value. Findings in March and June 2011 revealed slightly more deviation, with hematocrit of 39.7 percent and 37.7 percent, respectively. However, the April 2012 VA examiner, who reviewed the claims file, attributed the mild decrease in hematocrit to non-service connected diverticulosis. These lab tests do reveal low RBC on several occasions and low HGB of 13.6 g/dL in March 2011 and 12.9g/dL in June 2011; however, the April 2012 VA examiner, who, again, reviewed the claims file, was asked to check all of the signs and symptoms due to a stomach condition, including anemia, but she did not indicate that his disability was manifested by this disorder. Notably, both the January 2010 and April 2012 VA examination reports, which were based on review of the claims file, indicate that the service-connected gastric ulcer disability is not manifested by anemia. The January 2010 and April 2012 VA examination reports reflect that the service-connected gastric ulcer disability has not been manifested by anemia during the period since January 21, 2010. This conclusion is further supported by the April 2012 VA examiner's note that the Veteran had stopped taking iron over two years earlier. Moreover, despite the assessments of anemia noted in the VA treatment records in June and December 2010 and June and December 2011, each of these assessments noted that laboratory studies were pending. Letters from the Veteran's nurse practitioner to the Veteran regarding his lab tests following his treatment on each of these dates do not discuss anemia. Even assuming that the findings of anemia in the VA treatment records during this period, and/or the lab findings referenced above, demonstrate anemia since January 21, 2010, the evidence does not reflect significant weight loss other than a single 10 pound weight loss between August and September 2010. Significantly, the Veteran described his weight as stable on VA examination in January 2010 and denied a change in his weight in the past year. In September 2010 it was noted that the Veteran's weight had been fairly stable until his recent loss of about 10 pounds. Despite this weight loss, the record reflects that he subsequently gained weight and, in December 2010, the Veteran denied any weight loss or appetite loss. Another treatment record from the same month describes his weight as stable. Notably, the April 2012 VA examiner was asked to check all of the signs and symptoms due to a stomach condition, including weight loss, but did not indicate that the Veteran's disability was manifested by this. The VA treatment records reveal that the Veteran's weight remained between 185 and 189 pounds between January and August 2010 and, while there was some fluctuation between 173.6 pounds and 184.5 pounds between September 2010 and January 2012, there were no findings of notable weight loss other than the 10 pound weight loss discussed above. In fact, after the 10 pound weight loss, the next largest fluctuation in weight was a loss from 178.4 pounds in September 2011 to 174.2 pounds one month later, a difference of only 4.2 pounds. Further, from January to February 2012, the Veteran gained from 184.5 to 187.1 pounds. The service-connected gastric ulcer disability has not resulted in impairment of health manifested by anemia and weight loss during the period in question, as contemplated in a 60 percent rating pursuant to Diagnostic Code 7304. Further, there is no evidence of recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. Rather, on VA examination in January 2010, the Veteran denied incapacitation in the past year and stated that he had not been prescribed bedrest. Significantly, during the April 2012 VA examination, he reported that he had not been prescribed bedrest for a stomach condition within the last five years and the examiner specifically noted that the Veteran did not have incapacitating episodes due to signs or symptoms of any stomach condition. In light of the foregoing, the Board finds that the Veteran's gastric ulcer disability does not more nearly approximate a moderately severe disability during the period in question. The April 2012 VA examiner noted that the Veteran experienced periodic abdominal pain at least monthly which was only partially relieved by standard ulcer therapy. While such a finding is consistent with a 60 percent rating under Diagnostic Code 7304, the other manifestations of a severe ulcer disability as described in that diagnostic code, including recurrent hematemesis or melena have not been demonstrated during this period. Indeed, the Veteran denied hematemesis and melanotic stools on VA examination in January 2010; he denied vomiting of blood during VA treatment in May 2010; and he denied hematemesis on VA examination in April 2012. While the Veteran reported episodes of vomiting during VA treatment in July 2010 and complained of vomiting the following month, he reported in August 2010 that his symptoms were controlled relatively well with medication. He denied vomiting on VA examination in January 2010, during VA treatment in May and July 2010, and on VA examination in April 2012. Therefore, periodic vomiting has not been shown. Additionally, as discussed above, the Veteran does not have anemia and weight loss productive of definite impairment of health. Thus, the Veteran's gastric ulcer disability does not more nearly approximate a severe disability during the period in question. The conclusions that the Veteran's service-connected disability does not more nearly approximate moderately severe or severe disability during this period are further supported by the Veteran's own January 2010 statement that he had no impediments to his activities of daily living and the April 2012 VA examiner's finding that his service-connected disability resulted in only mild functional limitations. Most recently, the Veteran himself reported in April 2012 that his medicine was working and he rarely had stomach problems. An increased rating pursuant to Diagnostic Code 7304 is not warranted during this period. 38 C.F.R. § 4.114, Diagnostic Code 7304. While an increased, 30 percent rating is available pursuant to Diagnostic Code 7307, the evidence during this period does not demonstrate chronic hypertrophic gastritis with multiple small eroded or ulcerated areas and symptoms. Rather, a January 2010 upper GI study revealed no evidence of peptic ulceration or obstruction. While a December 2010 EGD did reveal erosive gastritis in the antrum and body of the stomach, the report does not note multiple small eroded areas. More recently, October and November 2011 EGD reports note no gastric erosion. The November 2011 report also notes no ulcers in the stomach. Further, June 2010 and May 2011 biopsies revealed only mild gastritis. Most recently, the April 2012 VA examiner indicated that there were no objective findings of gastritis or an ulcer, based on her review of a December 2011 EGD. In light of these findings, a 30 percent rating pursuant to Diagnostic Code 7307 is not warranted. 38 C.F.R. § 4.114, Diagnostic Code 7307. The Board has considered whether an increased rating is warranted pursuant to Diagnostic Code 7346; however, the evidence does not reflect that the Veteran's disability is manifested by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health, as required for an increased, 30 percent rating. Rather, although the Veteran has described epigastric burning during this period, he denied pain on VA examination in January 2010 and, during VA treatment for complaints of reflux in August 2010, the Veteran reported that his symptoms were controlled relatively well with medication. In March 2011, he reported that his reflux symptoms were not as bad as they had been since he started taking a GI "cocktail" before bedtime, and he added that he was no longer waking up choking. During the April 2012 VA examination, the Veteran indicated that his reflux symptoms had been controlled with medication until the last month, and he added that his symptoms had already started to decrease since a new medication had been added. As stated above, five days later, the Veteran reported that his medicine was working and he rarely had stomach problems. Of note, no gastroesophageal reflux was identified on barium esophagram in July 2011. In light of this evidence, an increased, 30 percent rating pursuant to Diagnostic Code 7346 is not warranted. 38 C.F.R. § 4.114, Diagnostic Code 7346. For all the foregoing reasons, a rating in excess of 20 percent is not warranted from January 21, 2010. Both Periods The Board has considered that the medical evidence during both periods discussed above includes multiple complaints regarding and treatment for recurrent candida esophagitis; however, this is not a service-connected disability. Indeed, the April 2012 VA examiner described the Veteran's esophageal candidiasis as non-service connected and stated that this condition was associated with daily prednisone use for rheumatoid arthritis. She noted that this was not incurred in or caused by postoperative gastric ulcers with gastritis. Where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). However, as the medical evidence currently of record does not specifically distinguish between symptoms attributable to the Veteran's service-connected gastric ulcer and those attributable to candida esophagitis, all of the esophageal symptomatology has been considered related to his service-connected disability. See Mittleider, 11 Vet. App. 181. The Board has also considered whether the Veteran is entitled to a separate evaluation for surgical scars related to his service-connected gastric ulcer disability. See Esteban v. Brown, 6 Vet. App. 259 (1994). However, these scars have not been described as painful, and have not been found to be unstable, exceed 144 square inches, or to be deep or cause limited motion. Rather, these scars have been described as well-healed. A separate compensable evaluation is not therefore warranted. 38 C.F.R. § 4.118. The above determinations are based upon consideration of pertinent provisions of VA's rating schedule. The Board has considered entitlement to an extra-schedular rating for the service-connected gastric ulcer disability. However, the Veteran's gastric ulcer disability does not markedly interfere with his ability to work, meaning above and beyond that contemplated by schedular rating. While the Veteran stated in March 2009 that he had cramping and had to miss work because of his persistent diarrhea and reported during the January 2010 VA examination that he had missed at least 14 days of work in the past year because of diarrhea, some interference with employment is already contemplated by the disability ratings that are assigned. The record reflects that the Veteran has remained employed during the pendency of this appeal. Thun v. Peake, 22 Vet. App. 111, 115-116 (2008). Generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1; VAOPGCPREC 6-96. See also, Bagwell v. Brown, 9 Vet. App. 337, 338 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). There is no medical evidence or lay assertion of "marked interference with employment" due to the gastric ulcer disability to render impractical the application of the regular rating standards. See 38 C.F.R. § 3.321(b)(1). Finally, there is no evidence of any other exceptional or unusual circumstances, such as frequent hospitalizations due to his service-connected gastric ulcer disability, to suggest he is not adequately compensated by the regular Rating Schedule. See 38 C.F.R. § 3.321(b)(1); VAOPGCPREC 6-96. Rather, since his August 2003 surgery, this disability has required only outpatient treatment and the Veteran himself reported in April 2012 that he rarely had stomach problems. The Board has resolved reasonable doubt the Veteran's favor in determining that a 40 percent rating is warranted for the service-connected gastric ulcer disability from October 1, 2003 to January 21, 2010, but finds that the preponderance of the evidence is against assignment of a rating greater than 20 percent since January 21, 2010. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER A 40 percent rating for a gastric ulcer is granted from October 1, 2003 to January 21, 2010. A rating in excess of 20 percent for a gastric ulcer, from January 21, 2010, is denied. ____________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs