Citation Nr: 1305898 Decision Date: 02/20/13 Archive Date: 02/27/13 DOCKET NO. 08-16 694 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for a digestive disorder, to include duodenal ulcer disease. REPRESENTATION Appellant represented by: American Red Cross WITNESSES AT HEARING ON APPEAL Appellant and the appellant's son ATTORNEY FOR THE BOARD J. Fussell, Counsel INTRODUCTION The Veteran served on active duty from April 1957 to April 1959 and from October 1961 to August 1962. This matter initially came before the Board of Veterans' Appeals (Board) from an appeal from a January 2008 rating decision issued by the Regional Office (RO) in Roanoke, Virginia. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. The Veteran testified before the undersigned Acting Veterans Law Judge at a March 2010 hearing. A transcript of that hearing is on file. When the Board remanded for VA treatment records in May 2011, the issues included whether new and material evidence had been received to reopen two claims for service connection. In July 2012 Board found that new and material evidence had been received, and reopened to claims but deferred de novo adjudication pending VA nexus examinations. Thereafter, a September 2012 rating decision granted service connection for acne, with a history of sebaceous cysts and scarring of the left side of the neck, which was assigned an initial 10 percent disability rating, both effective 10, both effective October 15, 2007. The Veteran has not disagreed with the initial noncompensable rating assigned or the effective date. As there is no jurisdiction conferring Notice of Disagreement (NOD) to the downstream elements of effective date or compensation level, no such issues are now in appellate status. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). As that decision constituted a full grant of the benefits sought on appeal, the issue of entitlement to service connection for a skin disorder is not currently in appellate status before the Board. The case has now been returned to the Board. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. A digestive disorder, specifically duodenal ulcer disease, first manifested during the Veteran's second period of active service. 2. The duodenal ulcer disease which manifested during the Veteran's second period of active service was acute and transitory, and resolved without residual disability. 3. The Veteran now has gastroesophageal reflux disease which first manifested many years after both periods of active service and is unrelated to either period of military service, including the duodenal ulcer disease during his second period of active service. CONCLUSION OF LAW The criteria for a digestive disorder, to include duodenal ulcer disease, are not met. 38 U.S.C.A. §§ 1112, 1113, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist VA has a duty to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, et seq (effective November 9, 2000) (Veteran Claims Assistance Act of 2000 (VCAA)); see also 38 C.F.R. §§ 3.102, 3.156(a), 3.159. VA must provide notice of (1) information and evidence, medical or lay, needed for claim substantiation, (2) which portion that VA will seek to provide; and (3) that which the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159; see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). This duty to notify was intended to be provided prior to an initial adjudication of a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004) (Pelegrini II). For a claim, as here, pending before VA on or after May 30, 2008, 38 C.F.R. § 3.159 was amended to eliminate the requirement that VA also request that the submission of evidence in the claimant's possession that might help in claim substantiation. See 73 Fed.Reg. 23353 (Apr. 30, 2008). The VCAA notice was intended to be provided prior to the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The VCAA notice requirements apply to all five elements of a service connection claim which are: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was provided with pre-adjudication VCAA notice by letter, dated in November 2007. He was notified of the evidence needed to substantiate the service connection claim, i.e., evidence of a current disability, disability during or event during service and a relationship between the two. He was notified of the evidence needed to substantiate a service-connection claim and the types of evidence the Veteran was expected to provide and that which VA would obtain on his behalf, e.g., private, VA or other Federal records. That letter also informed the Veteran of how a disability rating or an effective date would be established if service-connection were granted, in accordance with Dingess v. Nicholson, 19 Vet. App. 473 (2006). Moreover, as the claim is denied, no disability rating and effective date will be assigned as a matter of law. Therefore, there can be no possibility of any prejudice to the Veteran with respect to any defect in the VCAA notice required under Dingess, at 19 Vet. App. 473. See VAOPGCPREC 8-2003 (Dec. 22, 2003); Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007) and Bernard v. Brown, 4 Vet. App. 384, 394 (1993). As to the duty to assist, required by 38 U.S.C.A. § 5103A, VA has made reasonable efforts to identify and obtain relevant records for claim substantiation. The Veteran's service treatment records (STRs) have been obtained. His VA treatment records are on file, and private treatment records have been obtained. The Veteran testified in support of his claim at a hearing before the undersigned Acting VLJ. It must be noted that the STRs reflect that the Veteran was treated prior to his second period of service by a private, family physician. However, these records are not on file. As to this, the Veteran has specifically denied, in his testimony, having been treated for gastrointestinal disability prior to his second period of service. Accordingly, the only rational conclusion which may be reached is that it would be futile to request the Veteran to provide the information needed to obtain such records. The VCAA duty to assist is predicated on the requirement that the claimant provide sufficient information to identify the relevant records. 38 U.S.C.A. § 5103A(b)(1). The duty to assist is limited to specifically identified documents that by their description would be facially relevant and material. Gobber v. Derwinski, 2 Vet. App. 470, 472 (1992) (citing Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) and Colvin v. Derwinski, 1 Vet. App. 171, 174 (1991)). Additionally, the Veteran has been given a VA examination as to his service-connection claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). The VA examination in August 2012 yielded an informed medical opinion which directly responded to the question posed in the Board's 2012 remand. Further, in response to the May 2011 Board remand, additional VA treatment records were obtained, as requested, including those from 1970 to 1999. Here, the 2012 VA examiner reviewed the STRs, the entire claim files, noted the Veteran's history, and conducted a physical examination. Also, a gastrointestinal series was performed. The examiner found that the current gastrointestinal symptoms were due to a cause unrelated to military service, and explained why. Thus, the Board finds that the examiner adequately explained the basis for the opinion which was reached. Also, the adequacy of the examination and medical opinion obtained has not been challenged. As to this, even in light of the duty to independently consider issues suggested by the evidence of record, under Comer v. Peake, 552 F.3d 1362, 1368 (Fed.Cir. 2009), "the Board is entitled to assume the competence of a VA examiner unless the competence is challenged. Rizzo [v. Shinseki,] 580 F.3d at 1290-91. The argument that a VA medical examiner's opinion is inadequate is sufficiently close to the argument raised in Rizzo that it should be treated the same." Sickels v. Shinseki, 643 F.3d 1362, 1366 (Fed. Cir. 2011); see also Bastien v. Shinseki, 599 F.3d 1301, 1307 (Fed.Cir. 2010); and Cox v. Nicholson, 20 Vet. App. 563, 569 (2007); Hilkert v. West, 12 Vet. App. 145, 151 (1999). Accordingly, there has been full compliance with the Board's remands. See generally Stegall v. West, 11 Vet. App. 268 (1998). D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). As there is no indication that the Veteran was unaware of what was needed for claim substantiation nor any indication of the existence of additional evidence for claim substantiation, the Board finds these actions have satisfied VA's duty to assist and that no additional assistance is required. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). The Board has thoroughly reviewed all the evidence of record. The Board has an obligation to provide reasons and bases supporting any decision, but there is no requirement to discuss, in detail, all pieces of evidence on file, or submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81(Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show. The Veteran must not assume that the Board has overlooked pieces of evidence which are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122(2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to a veteran). Background Service treatment records (STRs) of the Veteran's first period of active service are negative as to his gastrointestinal and digestive system. The October 1961 examination for entrance into the Veteran's second period of active service was negative as to his gastrointestinal and digestive systems, but an adjunct medical history questionnaire noted that he had or had had stomach, liver or intestinal trouble. An October 1961 clinical record reflects a notation of the Veteran's having had "ulcers" for 1 year. Later that month it was again noted that he had a "hist [sic] of 'ulcer' with pain" and hematuria. He had been treated for gastrointestinal symptoms by his family physician. A November 1961 gastrointestinal fluoroscopy revealed the Veteran's esophagus and stomach appeared normal. The duodenum was slightly deformed and on a second film there was a small crater noted in the apical portion of the duodenum. The conclusion was that his stomach and esophagus were normal but there was a slightly deformed duodenum with a small crater. A clinical record in December 1961 noted that the Veteran was hospitalized, apparently for acute gastrointestinal symptoms. The discharge summary reflects that he was hospitalized from the 5th to the 15th of that month. He reported having been treated by a local physician for an ulcer but had never had an X-ray. He had been on medication and diet for approximately one year. He had been on sick call several times and, during service, was treated conservatively but had not been on any diet. A gastrointestinal series had revealed a small duodenal ulcer, which was the reason for his current admission. A physical examination was negative. During his hospitalization he was placed on a sippy diet, which was progressive up until being on a bland diet. He was given antacids in the form of "probanthine" and was given Gelusil, and sedation with Phenobarbital. During his hospitalization he had minimal epigastric discomfort. After 10 days, it was felt he could be discharged and could continue on a diet as an outpatient. The discharge diagnosis was an ulcer of the duodenum. In January 1962 the Veteran was noted to be on a bland diet because of his ulcer. He had no melena or vomiting now but complained of having epigastric burning. Continuation of a bland diet and medication was recommended. The June 1962 examination for separation from the second period of service was negative. However, in an adjunction medical history questionnaire the Veteran reported having or having had stomach, liver or intestinal trouble. It was reported that he had been treated for peptic ulcer disease in December "1962" and his symptoms still occurred. VA records of hospitalization and outpatient treatment in 1972 do not reflect any gastrointestinal complaints or findings and his hospitalization was not for gastrointestinal disability. On VA examination in March 1982 the Veteran complained of stomach problems. It was noted that he had been hospitalized during service for stomach ulcers for 3 weeks. He had had trouble with his stomach since then. He did not know if the ulcer was in the stomach or duodenum. He had not had surgery or any bleeding but had occasional night pain and occasional vomiting. He had had an acute flare-up one year ago and had been treated as an outpatient. He had been off work for 30 days. He reported that he got along pretty well unless he became upset. His situation stayed about the same. A physical examination disclosed no pertinent abnormality. A current upper gastrointestinal series revealed his esophagus and esophagogastric junction were normal. There was no evidence of a hiatal hernia. His stomach was normal in tone and position. There was no ulcer crater or malignancy. The duodenal bulb, duodenal loop, and upper jejunum were within normal limits. The impression was a normal upper gastrointestinal series. The final relevant diagnosis was a peptic ulcer, by history. Following the April 1982 RO denial service connection for a duodenal ulcer, in the Veteran's application to reopen in August 1990 he reported that he still had flare-ups of ulcers, for which he had been treated by VA. However, he was notified by letter dated October 3, 1990, that to reopen he had to submit new and material evidence as soon as possible. He was also provided information as to his appellate rights. However, the Veteran did not submit additional evidence, as requested in the October 1990 RO letter, nor did he appeal the October 1990 determination that new and material evidence was needed. VA treatment records from 1990 to 1999 reflect complaints and treatment primarily for lumbosacral disability but no gastrointestinal complaints or treatment, although there was a May 1999 clinical notation that he had a history of peptic ulcer disease. The Veteran's most recent application to reopen the claim for service connection for a gastrointestinal disorder was received on October 15, 2007, in which he again reported having been treated by VA. VA outpatient treatment (VAOPT) records from 1991 to 2001 reflect that in 1999 he took Tagamet for stomach problems. In January 2001 it was noted that he had a history of peptic ulcer disease. In August 2002 it was noted that his prescription for Tagamet was to be changed to Zantac. In October 2005 the diagnoses included peptic ulcer, not otherwise specified, based on a computerized problem list. Records from Skyline Family Practice show that the Veteran's prescription for Prilosec was doubled in September 2007, but his Zocor was stopped. In October 2007 his stomach still bothered him. The assessment was abdominal epigastric pain. VAOPT records show that in December 2008 the Veteran was to continue taking Prilosec and if his symptoms continued he should have an endoscopy. His active problem list included peptic ulcer, not otherwise specified (based on a computerized problem list). VAOPT records show that in December 2008 it was reported that the Veteran had a history of having had peptic ulcer disease since the 1970s, and he continued to have abdominal discomfort, including reflux symptoms. At the March 2010 hearing the Veteran testified that he did not recall having any problems with his stomach prior to his second period of military service; rather, they began a few months after entering that period of service, in 1961, and he then had to take medication. Page 8 of the transcript of that hearing (T8). During service he had diarrhea and vomiting, and was told that he had an ulcer, for which he was put on a bland diet for the remainder of his military service. He was even hospitalized for his ulcer. His medications during service included Tagamet. T9. Following service he remained on a special diet. He still had abnormal sensations in his stomach. He had been evaluated for his stomach by VA in November 2007. T10. He continued to have gastrointestinal flare-ups. T11. He again stated that he had not had a stomach condition prior to his military service. T12. The Veteran's son testified that since the Veteran's military service he had seen the Veteran take medications for his stomach and heard him complain about his stomach. He had taken Rolaids on a regular basis and had been prescribed medications. He had also been on a special diet. T12. An April 2010 VA upper gastrointestinal series revealed the Veteran's esophagus, stomach, and duodenum were normal. On VA gastrointestinal examination in August 2012 the Veteran's claim file was reviewed. It was reported that the Veteran now had or had had a duodenal ulcer. He had been treated for a duodenal ulcer during service and reported that since that time he had had gas, heartburn, and reflux. He had to be careful what he ate because spicy and greasy foods aggravated his symptoms. He denied having hematemesis or melena. His treatment plan included continuous medication for his diagnosed condition. These were Omeprazole with occasional TUMS or Rolaids. As to signs or symptoms of his duodenal condition, the Veteran had recurring episodes of symptoms that were both severe and episodes that were not severe, 4 or more times per year lasting less than a day. He had recurring episodes of nausea 4 or more times a year, lasting less than a day. He did not have hypertrophic gastritis or any gastrointestinal surgical residuals. An upper gastrointestinal series revealed his esophagus, stomach, and duodenum were normal and there was no evidence of ulcer disease or a hiatal hernia. He described having severe heartburn. The examiner reported that the Veteran's gastrointestinal disorder was less likely than not incurred in or caused by military service. The rationale was that the Veteran had symptoms of reflux and also had been diagnosed to have this stomach disorder. He had an uncomplicated duodenal ulcer during service in 1961, and there was no evidence, from a review of the records, that it recurred, nor had it persisted. The symptoms during service did not suggest reflux. A review of VA records revealed treatment and hospitalization for low back pain, and back surgery. He had been on Tagamet for a "hx of duodenal ulcer" and stomach problems, but no active complaint typical of ongoing or chronic digestive problems. A gastrointestinal series in 2010, and currently, did not reveal any scarring or evidence of an acute ulcer. It was less likely that his current digestive problem, which clinically was gastroesophageal reflux disease (GERD), was secondary to or related to the duodenal ulcer which was treated during military service. Principles of Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131 (West 2002). Service connection requires that there be (1) competent evidence of a current disability, (2) medical or lay evidence of in-service incurrence or aggravation of disease or injury, and (3) competent evidence, medical or lay, of a nexus between the claimed in-service injury and the present disability. Dalton v. Nicholson, 21 Vet. App. 23, 36 (2007). A showing of inservice chronic disease requires evidence of (1) a sufficient combination of manifestations for disease identification, and (2) sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." A showing of continuity of symptoms is not required when a chronic disease identity is established but is required when inservice chronicity is not adequately supported or when an inservice diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Certain conditions, such as peptic (gastric or duodenal) ulcer disease, will be presumed to have been incurred in service if manifested to a compensable degree within 1 year after service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. 38 C.F.R. § 3.309 also provides that "[a] proper diagnosis of gastric or duodenal ulcer (peptic ulcer) is to be considered established if it represents a medically sound interpretation of sufficient clinical findings warranting such diagnosis and provides an adequate basis for a differential diagnosis from other conditions with like symptomatology; in short, where the preponderance of evidence indicates gastric or duodenal ulcer (peptic ulcer). Whenever possible, of course, laboratory findings should be used in corroboration of the clinical data." To establish continuity of symptomatology requires (1) that a condition was 'noted' during service, (2) evidence of postservice continuity of the same symptomatology, and (3) medical or lay evidence of a nexus between the present disability and the postservice symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The Board must find whether the preponderance of the evidence is against the claim. If so, it is denied, but if the preponderance supports the claim or the evidence is in equal balance, the claim is allowed. 38 U.S.C.A. § 5107 (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1365-66 (Fed. Cir. 2001); 38 C.F.R. § 3.102. If the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. Analysis It is undisputed that the Veteran did not have any gastrointestinal disability, including any ulcer disease, prior to or during or even within one year of his April 1959 discharge from his first period of active service, and it is not otherwise contended. The examination for entrance into his second period of active service also did not reveal any gastrointestinal disability, including ulcer disease. Despite the Veteran's testimony to the contrary, the medical history questionnaire in conjunction with the examination for entrance into his second period of service indicated that he had had some type of stomach, liver or intestinal problem. Similarly, during his second period of active service there were several notations that he had been treated for "ulcers" for a significant period of time prior to his second period of active service. As to this, a Veteran is presumed to be in sound condition upon examination for entrance into active service except for disability found upon such examination. This presumption of soundness can only be overcome if there is (1) clear and unmistakable evidence that the claimed disability pre-existed military service; and, (2) there is clear and unmistakable evidence that it was not aggravated during that period of active service. The burden then falls on VA to rebut the presumption of soundness by clear and unmistakable evidence that an injury or disease manifested in service was both preexisting and not aggravated by service. See 38 U.S.C. § 1111; Wagner, 370 F.3d at 1096; Bagby, 1 Vet. App. at 227. This statutory provision is referred to as the "presumption of soundness," the rebuttal of which requires proof both as to pre-existence (the pre-existence prong) and lack of aggravation (the aggravation prong). A '[h]istory of preservice existence of conditions recorded at the time of [entrance] examination does not constitute notation of such conditions but will be considered together with all other material evidence in determinations as to inception." 38 C.F.R. § 3.304(b)(1). In other words, a notation in an entrance medical history questionnaire, standing alone, does not rebut the presumption of soundness. Thus, the notation in the 1961 entrance medical history questionnaire, standing alone, does not rebut the presumption of soundness. There remains, however, the question of whether this notation, rebuts the presumption of soundness when it is considered together with the other inservice clinical notations that the Veteran had been treated prior to his second period of active service. The Board concludes that it does not. This is because the standard for rebutting the presumption of soundness requires clear and unmistakable evidence of the pre-existence of the claimed disability. Here, the Veteran's testimony was under oath may not be taken lightly. That testimony was to the effect that he had not been treated, or at a minimum could not recall having been treated, for gastrointestinal disability prior to service. If he had been treated prior to the relevant period of service for gastrointestinal disability, it is not likely to be something which he would be unable to recall. Thus, the record as a whole does not clearly and unmistakably establish that the Veteran had gastrointestinal disability, including ulcer disease, prior to his second period of active service. This matter having been resolved, there remains the question of whether the Veteran now has gastrointestinal disability, including duodenal ulcer disease, which was incurred during his second period of active service, or duodenal ulcer disease which manifested within one year of his August 1962 discharge from that period of active service. In this regard, it is undisputed that the Veteran had and was treated for duodenal ulcer disease during his second period of active service. Thus, the first element needed for service connection, evidence of in-service incurrence of disease, is established. There remains the question of whether he now has the same gastrointestinal disability which he had during his second period of active service. For the reasons explained, the Board concludes that he does not. The Board must address the Veteran's lay testimony that the gastrointestinal symptoms he now has are the same as the symptoms during his active service, and as to which he testified he had continuously had since his inservice duodenal ulcer treatment. Lay evidence is competent when a condition can be identified by a layperson. See 38 C.F.R. §§ 3.159(a)(1) and(2) (defining competent medical and lay evidence) and 3.307(b) (as to chronicity and continuity of symptoms lay evidence should describe material and relevant facts observed and not merely conclusions based upon opinion). Lay evidence may, in some circumstances, establish a medical diagnosis, causation or etiology, i.e., when a layperson (1) is competent to identify the medical condition, (2) is reporting a contemporaneous medical diagnosis, or (3) describes symptoms at the time which supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir. 2009) (overruling the broad holdings in Buchanan v. Nicholson, 451 F.3d 1331 (Fed.Cir. 2006) and Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (2007) that competent medical evidence is required when the determinative issues if either medical etiology or a medical diagnosis); see also King v. Shinseki, 700 F.3d 1399 Fed.Cir. 2012); 2012 WL 6029502 (C.A.Fed.) (confirming that Davidson, Id., overruled the broad holdings noted above in Buchanan, Id., and Jandreau, Id.). The credibility of lay statements may not be refuted solely by the absence of corroborating medical evidence but this is a factor. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (lay evidence concerning continuity of symptoms after service, if credible, may be competent, regardless of the lack of contemporaneous medical evidence). Other factors are the lapse of time in recollecting events attested to, prior conflicting statements as opposed to consistency with other statements and evidence, internal consistency, facial plausibility, bias, interest, the length of time between alleged incurrence of disability and the earliest or first corroborating medical or lay evidence thereof, and statements given during treatment (which are usually given greater probative weight, particularly if close in time to the onset thereof). Here, the Veteran testified, in substance, that he was treated in the 1970s for gastrointestinal disability after military service. At the 1982 VA examination, the Veteran first related that after military service he had gastrointestinal symptoms similar to those for which he was treated during service and had been treated as an outpatient for the gastrointestinal symptoms. However, the Board has obtained his VAOPT records for this period. These records simply do not confirm that he was treated for any form of gastrointestinal disability or even that he had any gastrointestinal complaints. During his numerous outpatient treatment visits in the 1970s he had ample opportunity to report any gastrointestinal complaints or symptoms and to seek treatment therefor. However, he did not. Rather, it is not until almost 20 years after his discharge from his second period of service, at the 1982 VA examination, that he reported having any gastrointestinal symptoms which are now shown to be the basis of his current gastrointestinal disability, which is GERD. As to the Veteran's current gastrointestinal disability, the record simply does not show that he now has duodenal ulcer disease. Rather, the recent VA examiner, after interviewing the Veteran and reviewing the claim file, conclude that what the Veteran had during active service was no more than acute duodenal ulcer disease which resolved. And, also, that examiner found that what the Veteran now has is GERD and, moreover, that the Veteran had not had GERD during active service. In this regard, the Board must note that repeated studies after service have found no active duodenal ulcer disease or, in fact, any abnormality of the duodenum. Gastroesophageal reflux is the "reverse flow of material from stomach to esophagus." Cox v. Brown, 5 Vet. App. 95, 97 (1993). The Board notes that under 38 C.F.R. § 4.114, Diagnostic Code 7305 (2012) some of the manifestations or rating criteria used for arriving at a disability rating under the Schedule For Rating Disabilities are anemia, weight loss, hematemesis, and melena. "Hematemesis is vomiting of blood." Vega v. Shinseki, No. 10-3483, slip op. (U.S. Vet. App. March 13, 2012); 2012 WL 803299; (nonprecendential memorandum decision) (citing DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 831 (32d ed. 2012)). "Melena is 'the passage of dark-colored feces stained with blood pigments or with altered blood'." Gilmore v. Shinseki, No. 10-2085 (U.S. Vet. App. Sept. 29, 2011); Slip Copy, 2011 WL 4489187 (Table); (nonprecendential memorandum decision) (citing DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1126 (32d ed. 2012)) There is no postservice evidence of hematemesis or melena. As stated by the 2012 VA examiner, the Veteran's symptoms since military service were those of GERD and not those of duodenal ulcer disease. The VA examiner made it clear that these are two different gastrointestinal disabilities. Distinguishing between these two disabilities requires medical education, training, and expertise of the type which the 2012 VA examiner possesses. On the other hand, the Veteran lacks these credentials and, so, he is not competent to render a medical opinion distinguishing and differentiating between these two disabilities. In sum, the VA examiner found, and the evidentiary record as a whole is consistent with a conclusion that while the Veteran had an acute duodenal ulcer during his second period of active duty, he had not had a duodenal ulcer thereafter. Rather, beginning a number of years after the second period of active service the Veteran had developed, and still has, GERD which is unrelated to the inservice duodenal ulcer disease and unrelated to the Veteran's periods of miliary service. This being the case, the claim must be denied because the preponderance of the evidence is unfavorable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for a digestive disorder, to include duodenal ulcer disease, is denied. ____________________________________________ J. W. FRANCIS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs