Citation Nr: 1303441 Decision Date: 02/01/13 Archive Date: 02/08/13 DOCKET NO. 08-13 031A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for esophagitis and other chronic gastrointestinal disorders other than gastritis. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Bernard T. DoMinh, Counsel INTRODUCTION The Veteran served on active duty from June 1968 to May 1971. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a November 2004 rating decision by the Cleveland, Ohio, Regional Office (RO) of the Department of Veterans Affairs (VA) which, inter alia, denied the Veteran's claim of entitlement to service connection for gastritis, esophagitis, and other chronic gastrointestinal disorders. During the course of the appeal, the Veteran was awarded service connection for gastritis by rating decision dated in April 2008. Thusly, the appeal remains ongoing with respect to the remaining gastrointestinal disabilities for which VA compensation is claimed. FINDINGS OF FACT 1. The Veteran is service connected for chronic low back pain with degenerative joint disease (DJD), degenerative disc disease (DDD), and bilateral radiculopathy. 2. The medical evidence establishes that the Veteran's chronic gastroesophageal reflux disease (GERD) and esophagitis are etiologically related to his long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) and narcotic medications for treatment of his service-connected low back disability. 3. The medical evidence establishes that the Veteran's chronic constipation is etiologically related to his long-term use of narcotic medications for treatment of his service-connected low back disability. 4. The medical evidence establishes that the Veteran's chronic residuals of a subtotal colectomy for treatment of bowel obstruction are etiologically related to colonic dysmotility associated with his long-term use of narcotic medications for treatment of his service-connected low back disability. 5. The medical evidence establishes that the Veteran's chronic residuals of a subtotal colectomy for treatment of bowel obstruction is etiologically related to extensive abdominal adhesions that are themselves residuals of his history of abdominal surgery for treatment of GERD, which has been causally linked to his long-term use of medications for treatment of his service-connected low back disability. CONCLUSIONS OF LAW 1. GERD is proximately due to, or the result of the Veteran's service-connected low back disability. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.310(a) (2012). 2. Chronic esophagitis is proximately due to, or the result of the Veteran's service-connected low back disability. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.310(a) (2012). 3. Chronic constipation is proximately due to, or the result of the Veteran's service-connected low back disability. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.310(a) (2012). 4. Chronic residuals of a subtotal colectomy are proximately due to, or the result of the Veteran's service-connected low back disability. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.310(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 and VA's Duty to Assist. As will be further discussed below, the Veteran's claims of entitlement to service connection for esophagitis and other chronic gastrointestinal disorders (other than gastritis) are being granted in full. Therefore, the Board finds that any error related to VA's duties to notify and assist under the Veterans Claims Assistance of Act of 2000 (VCAA) (Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified at 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2011)) with regard to this claim is rendered moot by this fully favorable decision. See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159 (2012); Mayfield v. Nicholson, 19 Vet. App. 103, (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thusly, there is no need to engage in any analysis with respect to whether the requirements of the VCAA and VA's duties to notify and assist have been satisfied concerning this appeal. Service connection, generally. Service connection involves many factors, but basically means that the facts, shown by the evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if pre-existing such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. 38 C.F.R. § 3.303(a) (2012). Service connection may be granted for any disease diagnosed after discharge from active duty when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). In this regard, the Veteran is service connected for multiple chronic disabilities, the most relevant disability with regard to the current appeal being chronic low back pain with DJD, DDD, and bilateral radiculopathy (currently rated 60 percent disabling). It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102 (2012). Factual background and analysis: Entitlement to service connection for esophagitis and other chronic gastrointestinal disorders other than gastritis. The Veteran's service treatment records are negative for any report of or finding of any chronic disability affecting his upper and lower gastrointestinal tracts for the entirety of his period of active duty. Post-service medical records show that many years after separation from active duty, he was diagnosed and treated for chronic gastrointestinal disorders affecting his esophagus, esophageal sphincter, stomach, and colon. In addition to being diagnosed with gastritis, for which he is currently in receipt of VA compensation, he has been diagnosed with GERD, chronic esophagitis, and chronic constipation. Additionally, his medical history includes surgery for a subtotal colectomy for treatment of bowel obstruction. As relevant, the Veteran essentially contends that his current chronic gastrointestinal problems as discussed above are secondarily related to his service-connected chronic low back pain with DJD, DDD, and bilateral radiculopathy. He advances the theory that his long-term use of prescribed NSAIDs and narcotic painkillers produced gastrointestinal side effects that resulted in his GERD, chronic esophagitis, chronic constipation, and bowel obstruction (necessitating treatment through surgical resectioning of part of his large intestine). The Board notes that the Veteran's claims file includes an extensive collection of medical records and examination reports from private sources, VA, and the Social Security Administration (SSA), which are pertinent to his treatment for the aforementioned gastrointestinal disabilities. These records include opinions and medical discussion that imply, but do not definitively establish, a clinical relationship between these gastrointestinal disorders and the Veteran's prescribed medications for treatment of symptoms associated with his service-connected low back disability. Thusly, in early November 2012, the Board requested that the Veteran's claims file be referred to a VA medical expert for review, after which the medical expert was to provide a definitive medical opinion, supported by discussion and rationale, addressing the likelihood that the Veteran's claimed gastrointestinal disabilities were etiologically related to his service connected low back disorder. In late November 2012, the requested opinion was provided by the chief gastroenterologist of the Richmond, Virginia, VA Medical Center. The opinion was predicated on a review of the entire body of relevant medical evidence associated with the Veteran's claims file. The Board finds that its content represents the consolidated synthesis of these records, thereby obviating the need to discuss these preceding individual records in detail. The opinion is also highly probative evidence towards resolving the nexus questions raised by the claimant due to credentials of the opining physician and the fact that his medical conclusions represent the aggregate whole of the clinical evidence of record. In pertinent part, the November 2012 VA medical expert's opinion presents the follow clinical conclusions: 1. It is my opinion that it is at least as likely as not that the Veteran developed [GERD] and esophagitis as a result of medications [he] took for his [service-connected] low back disability. [The medical expert's rationale was that the Veteran's prescribed NSAIDs increased his gastric acidity and weakened the ability of his esophageal lining to resist damage from gastric acid, and that the prescribed narcotic painkillers decreased gastric motility and delayed gastric emptying, thus resulting in GERD and esophagitis.] 2. It is my opinion that it is at least as likely as not that the Veteran developed constipation as a result of medications [he] took for his low back disability. [The medical expert's rationale was that a well known side effect of using the narcotic painkillers prescribed to the Veteran was constipation, as the narcotics caused increased water absorption of stool by his large intestine, thus causing hard, dry stools that did not easily transit his colon.] 3. It is my opinion that it is at least as likely as not that the Veteran developed bowel obstruction as a result of medications [he] took for his low back pain and/or the hiatal hernia surgery [that he] underwent as treatment for [GERD]. [The medical expert's rationale was that the Veteran's bowel obstruction was the result of both colonic dysmotility and the presence of extensive abdominal adhesions. Colonic dysmotility was a known and common side effect of long-term prescribed narcotic use as such medications causes the colon to dilate, lose its propulsive activity in moving stool through its length, and thus result in a functional obstruction. The extensive abdominal adhesions noted in the Veteran obstructed his bowels and were attributed, in part, to his medical history of abdominal surgery for treatment of GERD, which in turn was attributed to prescribed medications for treatment of his service-connected low back disability.] Thusly, in view of the foregoing highly favorable medical opinion, the Board finds that the weight of the medical evidence supports a grant of service connection for GERD, chronic esophagitis, chronic constipation, and chronic residuals of a subtotal colectomy (for treatment of bowel obstruction), as these disabilities are secondary to the long-term pharmacological regimen prescribed to treat the Veteran's service-connected chronic low back pain with DJD, DDD, and bilateral radiculopathy. To the extent that there may be any doubt in this regard, the benefit of such doubt will be applied in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for GERD is granted. Service connection for chronic esophagitis is granted. Service connection for chronic constipation is granted. Service connection for chronic residuals of a subtotal colectomy is granted. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs