Citation Nr: 1307682 Decision Date: 03/07/13 Archive Date: 03/11/13 DOCKET NO. 04-22 787 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUE Entitlement to an increased rating for Prior to April 1, 2004, entitlement to an increased rating for non-steroidal anti-inflammatory medication (NSAID) induced gastritis evaluated as 10 percent disabling prior to April 1, 2004; as noncompensable from April 1, 2004 to September 26, 2012, and as 30 percent disabling since September 27, 2012. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Emily L. Tamlyn, Counsel INTRODUCTION The Veteran served on active duty from July 1997 to April 2000. This matter initially came before the Board of Veterans' Appeals (Board) from a January 2004 rating decision of the Department of Veterans' Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In that decision, the RO reduced the disability rating for gastritis from 10 percent to 0 percent and discontinued entitlement to a total disability rating for individual unemployability (TDIU), both effective April 1, 2004. Jurisdiction over the Veteran's claim was subsequently transferred to the RO in Boston, Massachusetts. In September 2005, the Veteran testified before a Veterans Law Judge at the RO (Travel Board hearing). A transcript of that hearing has been associated with her claims folder. In May 2007, the Board remanded several claims for further development. In July 2008, the Board denied the Veteran's appeal to restore a 10 percent rating for gastritis and remanded the claim for an increased rating for that disability and restoration of a TDIU for further development. In February 2011, the Board sent the Veteran a letter informing her that the Veterans Law Judge who conducted the September 2005 Travel Board hearing was no longer employed at the Board, asked her to indicate whether she wanted to attend a new hearing, and indicated that a failure to respond within 30 days would result in a presumption that another hearing was not desired. See 38 U.S.C.A. § 7107(c) (West 2002); 38 C.F.R. § 20.707 (2012). The Veteran did not respond to the February 2011 letter; and it is presumed that she does not want another hearing and the Board shall proceed to consider her appeal. In May 2011, the Board remanded the claim for an increased rating for gastritis in order to ensure that all VA records had been obtained and found that termination of the Veteran's TDIU was not done in accordance with applicable regulations, and hence the termination was not proper. The file reflects that VA has taken no action to implement the Board's decision that the termination of the TDIU was not properly done, and in effect restoring payment of the TDIU. The Veteran remains entitled to payment of TDIU. Also, as stated in the May 2011 Board decision and remand, the issue of entitlement to service connection for a gastrointestinal disability other than gastritis has been raised by the record has been raised by the record, but has not been adjudicated by the AOJ. The Board does not have jurisdiction over it, and it is again referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Prior to April 1, 2004, hypertrophic gastritis with multiple small eroded or ulcerated areas and symptoms were not shown. 2. From April 1, 2004 to September 26, 2012, hypertrophic gastritis with small nodular lesions and symptoms were not shown. 3. Since September 27, 2012, several hemorrhages or large ulcerated or eroded areas were not shown. CONCLUSIONS OF LAW 1. Prior to April 1, 2004, the criteria for a rating in excess of 10 percent for NSAID induced gastritis were not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.114, Diagnostic Code (DC) 7307 (2012). 2. From April 1, 2004 to September 26, 2012, the criteria for a compensable rating for NSAID induced gastritis were not met. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.114, DC 7307. 3. Since September 27, 2012, the criteria for an increased rating in excess of 30 percent for NSAID induced gastritis have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.114, DC 7307. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); Pub.L. 112-154, §§ 504(a)(1)-(2), 505(a)-(b) (Aug. 6, 2012) (to be codified at 38 U.S.C.A. §§ 5103(a)-(b), 5103A(b)-(c)); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2005). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by re-adjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The United States Court for Veterans Appeals (veteran's court or court) had held that at a minimum, adequate VCAA notice in an increased rating claim required that VA notify the claimant that, to substantiate such a claim: (1) the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life; (2) if the diagnostic code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant; (3) the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes; and (4) the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). The Federal Circuit vacated the Court's decision, overturning the requirement that VA provide notice that the claim could be substantiated by evidence of a disability's impact on daily life and that VA provide notice with regard to potential diagnostic code criteria (element 2). Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The generic first, third, and fourth elements (contained in the veteran's court's decision) were not disturbed by the Federal Circuit's decision. In the present case, complete notice was not issued prior to the adverse determination on appeal. However, fully compliant notice was later issued in December 2006 and May 2007 communications, and the claim was thereafter readjudicated several times. Accordingly, any timing deficiency has been cured. Mayfield, 444 F.3d 1328 (Fed. Cir. 2006). Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, her statements in support of the claim are of record, including testimony provided at a September 2005 Board hearing. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. In May 2011, the Board remanded this claim for additional VA medical records from the Columbus, Boston and Charleston VAMCs. The Board finds this action was accomplished (Although no further Columbus records were associated with the file, a December 2004 record shows the Veteran relocated to Boston from that area in summer 2004; pre-summer 2004 Columbus records are already in the file). The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the RO decision review officer or Veterans Law Judge who chairs a hearing fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the Veterans Law Judge identified the issues on appeal, and asked questions aimed at determining whether there was additional evidence that could substantiate the claims and obtaining information on the missing elements of the claims. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Increased Rating for Gastritis Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7 (2012). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability and coordination of rating with impairment of function are expected in all instances. 38 C.F.R. § 4.21 (2012). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012). Certain provisions apply to rating disabilities of the digestive system. For ulcers, 38 C.F.R. § 4.110 states that manifest differences in ulcers of the stomach or duodenum in comparison with those at an anastomotic stoma are sufficiently recognized as to warrant two separate graduated descriptions. In evaluating the ulcer, care should be taken that the findings adequately identify the particular location. Weight loss is addressed in 38 C.F.R. § 4.112, which states that for purposes of evaluating conditions in § 4.114, the term "substantial weight loss" means a loss of greater than 20 percent of the individual's baseline weight, sustained for three months or longer; and the term "minor weight loss" means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. The term "inability to gain weight" means that there has been substantial weight loss with inability to regain it despite appropriate therapy. "Baseline weight" means the average weight for the two-year-period preceding onset of the disease. Coexisting abdominal conditions are addressed under § 4.113. This section states there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14. See also Esteban v. Brown, 6 Vet App 259 (1994); 38 C.F.R. § 4.14 (2012). Similarly, 38 C.F.R. § 4.114 explains that ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. The Veteran's NSAID induced gastritis is currently rated under 38 C.F.R. § 4.114, DC 7399-7307. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27 (2012). Here, the use of DCs 7399-7307 reflects that there is no diagnostic code specifically applicable to the NSAID induced gastritis, and that this disability is rated by analogy to hypertrophic gastritis. See 38 C.F.R. § 4.20 (2012) (allowing for rating of unlisted condition by analogy to closely related disease or injury). The hypertrophic gastritis code notes that gastritis is to be identified by gastroscope. 38 C.F.R. § 4.114, DC 7399. If gastritis is chronic with severe hemorrhages, or large ulcerated or eroded areas, the rating is 60 percent. If it is chronic with multiple small eroded or ulcerated areas, and symptoms, the rating is 30 percent. Chronic gastritis with small nodular lesions and symptoms warrants a 10 percent rating. If it is atrophic gastritis (a complication of a number of diseases, including pernicious anemia) it is to be rated on the underlying condition. Id. Prior to April 1, 2004 Prior to April 1, 2004, the Veteran was receiving a 10 percent rating for NSAID induced gastritis. An in-service contract VA examination report from January 2000 showed the Veteran had developed intermittent pain in the epigastric area and NSAID use had to be discontinued. She continued to experience pain, especially after meals. She also mentioned she used to use a lot of NSAIDS to control headaches. There was evidence of mild epigastric tenderness to deep palpation. The examiner used this fact to diagnose NSAID-induced gastritis. While she was still in service in April 2000, a radiology report of a barium enema was negative. This appears to be the main diagnostic test given for gastroenterology complaints while in service. Service connection was granted effective April 15, 2000 (the date of separation from service) and a 10 percent rating under DC 7399-7307 was assigned. VA records show that in March 2002, the Veteran complained of stomach pain and was diagnosed with gastroesophageal reflux disease (GERD). She had acid reflux and was on Zantac. In December 2002, the Veteran submitted a statement that was eventually accepted as a claim for an increased rating. In May 2003, her notice of disagreement stated that medications for headache irritate her stomach. When her stomach hurt, she took Maalox and often a laxative. She changed her diet and eliminated caffeine, but it didn't seem to help. In February 2003, the VA examination report showed she had no nausea, vomiting, hemetemesis, diarrhea or melena. She had abdominal pain. She took Zantac and Pepto Bismol as needed. She had constipation, pain in the abdomen every two days which lasted until she took Pepto Bismol. She reported that an upper GI was done two years prior and she was told she had an ulcer. She had no weight change or anemia. An upper gastrointestinal series (GI) without kidney, ureter, and bladder (KUB) (an X-ray of the abdomen) showed GERD without a demonstrable hiatal hernia (see upper GI result of March 2003). There was no evidence of chronic peptic esophagitis or gastric or peptic ulcer disease. The diagnosis was GERD and the upper GI report did not show evidence suggestive of gastritis. In May 2003, a VA primary care record stated she was taking Maalox for gastritis. It also noted she had diagnostic testing at the VA examination recently. A review of systems noted no abdominal complaints. The assessment was GERD and constipation. Based on this evidence, the Board does not find that an increased rating for the time period on appeal is warranted. No increase is found under DC 7307 because no gastritis or nodular lesions were ever identified by gastroscope or by any other diagnostic test. The Board finds that gastritis is the predominant issue for the digestive disability picture on appeal. No ulcers were identified to warrant a rating under DC 7305. Although the Veteran said she was told she had an ulcer, the Board relies on the diagnostic testing and the 2003 VA examination report which determined no ulcer was present. The Veteran is otherwise competent to report her own digestive symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1377; Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). While the Board has considered other DCs under § 4.114 for this time period, it a rating in excess of 10 percent would not be warranted under those codes. From April 1, 2004 to September 26, 2012 The July 2008 Board decision denied the Veteran's appeal to restore the 10 percent rating for service-connected gastritis (the increased rating for a VA examination, finding that the reduction was appropriate based on the February 2003 VA examination report. From April 1, 2004 to September 26, 2012, the service-connected NSAID induced gastritis was noncompensable. A February 2005 VA primary care record notes an urgent care visit for epigastric burning pain unrelieved by TUMS or Pepto, constipation, and a history of "an ulcer, gastritis confirmed by endoscopy two years ago" (as stated above, the Board did not find such evidence in the file). For the past month had a lot of stress and reported increased burning pain unrelieved by over-the-counter medications. She said she "spit up acid feeling." Constipation was relieved by medication in the past. She had lower left quadrant pain with constipation. An examination showed the abdomen was soft, tender, with epigastric midline, and positive lower left quadrant pain. There was no rebounding or guarding and no mass. The assessment was reoccurrence of gastritis/reflux component; a trial of medication was planned for the next month; if the pain persisted, h. pylori or an upper GI was to be checked. A KUB or X-ray of the abdomen showed a moderate amount of stool in the ascending and rectosigmoid colon with no impaction. A March 2005, VA primary care record shows that GERD was in control with a proton-pump inhibitor (PPI). Her birth control (Desogen) caused bloating. (See May 2005 VA record.) A July 2005 VA urgent care record did show she had two days of abdominal pain, epigastric pain and suprapubic abdominal pain. She had a black stool about two weeks prior and a recurrent ulcer was to be ruled out, however, she was quaiac negative at the time and her abdominal examination was not overly concerning. She was scheduled for EGD and a PPI was started. At the September 2005 Board hearing, the Veteran said a neurologist in service just gave her pills and she ended up with an upset stomach, ulcer, nausea, vomiting, and other gastrointestinal symptoms. (Transcript, p 11.) She also began having constipation and loose bowels. (Transcript, p 11-12.) She was currently taking laxatives, a stool softener, and other medications. (Transcript, p 12.) She had dietary restrictions and acid reflux. Id. She did not vomit blood. (Transcript, p 13.) Weight loss was "up and down." Id. She went to the VA emergency room for gastrointestinal problems. (Transcript, p 14.) A private treatment record dated in April 2007, shows the Veteran had abdominal pain determined to be related to constipation. She had previously experienced diarrhea, but no blood. An X-ray showed an impression of constipation with no blood. The following month a VA primary care record referred her to gastroenterology (GI) clinic. The June 2007 VA GI consultation noted she had chronic constipation that was likely functional in origin and exacerbated by her psychiatric medications and psychiatric problems. Given her young age and lack of warning signs (no weight loss, blood in stool, or family history of GI malignancy), it was determined that her bowel regimen should be measured as opposed to invasive testing. Records document similar visits in February 2008 (private record) and January 2009 (VA primary care). A February 2009 VA primary care record determined that irritable bowel syndrome (IBS) and GERD were controlled. No bloody stools were reported during a June 2009 VA visit. During VA treatment in July 2009, the Veteran complained of abdominal pain. A colonoscopy was unremarkable. In August, she complained of abdominal pain and was told to increase fiber and not go three days without a bowel movement. In September 2009, a VA colon biopsy was normal. A December 2009 VA emergency room record showed a sudden onset of vomiting and diarrhea. In January 2010, a VA GI record noted that symptoms were consistent with constipation and IBS. The Veteran went to another VA examination in January 2010. The claims file was reviewed. Symptoms were noted of constipation, GERD and IBS. She had occasional melena with constipation. She watched her diet due to GERD; symptoms related to this were epigastric burning and regurgitation. She denied any problems with gastritis. Examination of the abdomen was normal. The diagnoses were IBS, GERD and no clinical or objective findings for a diagnosis of gastritis. A VA treatment record dated in March 2010, shows continued problems with abdominal pain, swelling and heartburn but she denied black or bloody stools. In a February 2011 VA phone call, the Veteran reported blood in her stool one day before but not that morning. The nurse wrote that this "sounded like severe constipation" and recommended medication. In March 2011 at a VA mental health appointment, the Veteran complained of stomach pain, described as right pelvic rim pain, but it was determined to be somatic. For this time period, the Board does not find that a compensable rating is appropriate. No increase is found under DC 7307 because no gastritis or nodular lesions were ever identified by gastroscope or by any other diagnostic test. Gastritis is the predominant service-connected digestive disability during this period; no ulcers were identified to warrant a rating under DC 7305. Despite reports of a past ulcer diagnosis, the Board relies on the diagnostic testing and the 2010 VA examination report which determined no clinical or objective findings for a diagnosis of gastritis or gastric lesions. As stated, the Veteran is otherwise competent to report her digestive symptoms. Jandreau, 492 F.3d at 1377; Buchanan, 451 F.3d at 1337. While the Board has considered other DCs under § 4.114 for this time period, the Veteran's symptomatology would not warrant a higher rating under those codes Since September 27, 2012 In October 2012, the AMC increased the service-connected NSAID induced gastritis to 30 percent disabling. In Mittleider v. West, 11 Vet. App. 181, 182 (1998) (citing 38 C.F.R. § 3.102), the Court of Appeals for Veterans Claims held that where the record does not separate the effects of a service-connected disability from the effects of a non-service-connected disability, the effects must be attributed to the service-connected disability or a medical determination must be obtained. There is evidence in the file that the Veteran has irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD). These issues have been referred by the Board and are not on appeal at this time, however, given § 4.113 and in consideration of Mittleider, 11 Vet. App. at 182, the Board will consider the applicable DCs for this time period. IBS can be rated under DC 7319; this code states that a 10 percent rating is warranted for moderate irritable colon syndrome with frequent episodes of bowel disturbances with abdominal distress and a 30 percent rating is warranted for severe irritable colon syndrome with diarrhea or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114, DC 7319. GERD can be rated under 38 C.F.R. § 4.114, DC 7346, addressing a hiatal hernia. Symptoms of pain, vomiting, material weight loss and hemetemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health are assigned a 60 percent rating. Persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health typify a 30 percent rating. Finally, a 10 percent rating is assigned with two or more of the symptoms for the 30 percent rating of less severity. At the September 2012 VA examination, the examiner did not find a history of ulcers or other stomach conditions, but noted a history of hypertrophic gastritis. Her medical history showed that the Veteran was first diagnosed with gastritis due to extensive ibuprofen use. Later, she was diagnosed as having IBS and GERD. Her "main issue" was constipation, although her weight was steady. The Veteran took medication for GERD and IBS. For gastritis, IBS and GERD, she had recurring episodes of symptoms that were not severe and were severe for four or more times per year for less than ten days at a time. She had monthly, pronounced, periodic abdominal pain only partial relieved by standard ulcer therapy. She had recurrent nausea, vomiting and melena or four or more times per year for less than ten days at a time. There were no incapacitating episodes. Hypertrophic gastritis was chronic with multiple small eroded or ulcerated areas and symptoms. The examiner cited to an upper endoscopy from 2000 which showed "multiple small ulcerations" as diagnostic testing reflecting the current condition, no such report is in the file. No report appears to have ever been created. The examiner stated she could not find it in the file. She relied on the Veteran's report that there were small ulcerations originally and assumed that an upper endoscopy had been completed before the original claim was granted. The examiner did note an April 2004 upper GI series which showed GERD without hiatal hernia or signs of gastritis (it's apparent from review of the file she was referring to the March 2003 upper GI study). She also noted the July 2009 colonoscopy which was normal. As for functional impact, the Veteran's digestive disabilities were found to impact her ability to work in that she could not take a laxative or give herself an enema at work; she had to stay at home until evacuation has finished or the enema has been accomplished. She sometimes had pain and bloating and would go home and lie down; occasionally she returned to work the same day but sometimes she had to wait until the next day. The post-service testing has not shown chronic gastritis and there have been no findings or report of severe hemorrhages, or large ulcerated or eroded areas. 38 C.F.R. § 4.114, DC 7399. There has been no post-service evidence by gastroscope showing that any lesions are present. In the September 2012 VA examination, the examiner opined that GERD and IBS were due to service. As explained, these issues are not currently before the Board and are referred to the RO for appropriate action. However, the Board has considered the other potentially applicable DCs for IBS and GERD. As the maximum rating is 30 percent under 38 C.F.R. § 4.114, DC 7319, no increased rating is warranted for this time period. GERD can be rated under 38 C.F.R. § 4.114, DC 7346, addressing a hiatal hernia. Symptoms of pain, vomiting, material weight loss and hemetemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health are assigned a 60 percent rating. The Board does not find such symptoms typify the Veteran's disability picture. No material weight loss, hemetemesis or anemia were found at the September 2012 VA examination, although she did have recurrent epigastric distress, dysphagia, heartburn, reflux, regurgitation, sleep disturbance, nausea, vomiting, and melena. She did not have esophageal stricture or other pertinent physical findings. In terms of functional impact, she sometimes had to leave her desk to get ginger ale and eat some crackers. Given these facts, the Board does not find that a 60 percent rating under DC 7346 best typifies the Veteran's disability picture. The provisions of 38 C.F.R. § 4.114 would prohibit separate ratings under Diagnostic Codes 7301-7329, 7331, 7342, or 7345-7346 for gastritis, GERD, and IBS. Elevation is not warranted, because beyond periods of constipation, diarrhea and pain, there has been little documented impairment of health and diagnostic testing has been essentially normal. The examiner stated that sometimes her hemorrhoids were aggravated by her constipation due to the IBS. IBS is not service-connected at this time, but considered for rating purposes due to the opinion of the September 2012 VA examiner. See Mittleider. Hemorrhoids are not included in the pyramiding considerations of § 4.114. In any case, under DC 7336, mild or moderate internal or external hemorrhoids (which are what the Veteran has according to the September 2012 VA examination report) do not warrant a compensable rating. See 38 C.F.R. § 4.114, DC 7336. Where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. See Hart, 21 Vet. App. at 509-510. However, the record does not support the assignment of different percentage evaluations during the time period on appeal. No staged rating is warranted. Extraschedular consideration and TDIU The Board has considered extraschedular ratings, further staged ratings and TDIU. Pursuant to 38 C.F.R. § 3.321(b)(1) (2012), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242, 244 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Initially, there must be a comparison between the level of severity and symptomatology of a claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors are marked interference with employment and frequent periods of hospitalization). The rating criteria fully contemplate the Veteran's disability as noted above, her symptomatology has consisted of constipation, diarrhea and abdominal pain. These symptoms are contemplated in the rating criteria. The rating criteria are therefore adequate to evaluate the Veteran's disability and referral for consideration of extraschedular rating is, therefore, not warranted. 38 C.F.R. § 3.321(b)(1). The Court has held that TDIU is an element of increased rating claims when such claim is expressly raised by the Veteran or reasonably raised by the record. Regarding a TDIU, in Rice v. Shinseki, 22 Vet. App. 447 (2009), The Board explained in its previous decision why the severance of the TDIU was improper. As a result of the Board's decision the Veteran has been entitled to a TDIU for the entire period of the appeal. ORDER Entitlement to an increased rating for NSAID induced gastritis is denied. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs