Citation Nr: 1308902 Decision Date: 03/15/13 Archive Date: 03/25/13 DOCKET NO. 09-34 809 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for irritable bowel syndrome (IBS), to include as secondary to service-connected PTSD. ATTORNEY FOR THE BOARD M. Young, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from November 1965 to November 1967. These matters are before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision by the North Little Rock, Arkansas Department of Veterans Affairs (VA) Regional Office (RO) that, in pertinent part, denied service connection for GERD, IBS, and erectile dysfunction. In January 2012 these matters were remanded for further development. An interim (August 2012) rating decision granted service connection for erectile dysfunction rated 0 percent, effective August 24, 2007, and that matter is no longer before the Board. FINDINGS OF FACT 1. The Veteran's GERD was not manifested in service, and is not shown to be related to his service, or to have been caused or aggravated by his service-connected PTSD. 2. The Veteran's IBS was not manifested in service, and is not shown to be related to his service, or to have been caused or aggravated by his service-connected PTSD. CONCLUSIONS OF LAW 1. Service connection for GERD, to include as secondary to PTSD is not warranted. 38 U.S.C.A. 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. Service connection for IBS, to include as secondary to PTSD is not warranted. 38 U.S.C.A. 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claims. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 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/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of the claims prior to the initial adjudication of his claims. September 2007 and July 2008, letters explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing, and the evidence the Veteran was responsible for providing, and explained how disability ratings and effective dates are assigned. The Veteran has had ample opportunity to respond/supplement the record, and has not alleged that notice in this case was less than adequate. Regarding VA's duty to assist, the Veteran's service treatment records (STRs), and postservice VA and private treatment records are associated with the claims file. A review of Virtual VA (VA's electronic database storage) found no additional pertinent information or evidence. Social Security Administration records have been secured. He was afforded VA examinations in September 2008 (with September 2008 addendum report), June 2009 (with July 2009 addendum report), and March 2012 (pursuant to Board remand). The Veteran has also submitted a report regarding his health from Joseph Boscarino, PhD, MPH, and an Internet article regarding side effects of some medications. He has not identified any other pertinent evidence that remains outstanding. Thus, VA's duty to assist is met. B. Legal Criteria, Factual Background, and Analysis Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. In general, service connection requires (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in- service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). A disease may be service connected if shown to be of a chronic nature in service, or if not chronic, then seen in service with continuity of symptomatology demonstrated after discharge. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Briefly, the legal requirements for a successful secondary service connection claim are: (1) evidence of a current disability for which secondary service connection is sought; (2) a disability which is service connected; and (3) competent evidence of a nexus between the two. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: A layperson is competent to identify the medical condition; the layperson is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Competent medical evidence means 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 mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). 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 layperson. 38 C.F.R. § 3.159(a)(2). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board notes all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal, has been reviewed. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. The Veteran contends that his GERD and IBS were caused or aggravated by his service-connected PTSD. He does not contend that either disorder was manifested in service and persisted. His STRs are silent regarding GERD and IBS. They do show that in July 1966 he reported a five-hour history of epigastric discomfort, with vomiting (once), fever, and light backache, with no diarrhea, constipation, or urinary discomfort. The impression was bacterial gastroenteritis. On September 1967 service separation examination he reported that he did not have nor ever had frequent indigestion, stomach trouble, intestinal trouble, piles, rectal disease, or recent gain or loss of weight. His abdomen, viscera, anus, and rectum were normal on clinical evaluation. The earliest report of any postservice complaints of symptoms associated with GERD and IBS in the record was many years after his discharge from service. Hence, service connection for the claimed disorders on the basis that they became manifest in service, and persisted, is not warranted. Furthermore, there is no competent evidence that relates the Veteran's current GERD and/or IBS to the episode of gastroenteritis in service. As discussed in greater detail below that episode was acute and self-limited. As there is nothing else to support that either of the claimed disorders is somehow directly related to service (nor so specifically alleged), service connection for GERD and/or IBS on a direct basis, i.e., that either disease was incurred or aggravated in service, is not warranted. The Veteran's theory of entitlement to the benefits sought is primarily one of secondary service connection. What is necessary to substantiate a secondary service connection theory of entitlement for the claimed disorders is there must be competent evidence that they were caused or aggravated by his service-connected PTSD (as alleged) or by another service-connected disability. Service connection has been established for PTSD, hypertension, erectile dysfunction, hearing loss, and tinnitus.. The pertinent evidence of record includes a November 2004 report from J. Boscarino, Ph.D, MPH, (a senior scientist for the New York Academy of Medicine, who has been involved with Veterans' health studies for 25 years) stating that "PTSD-positive veterans had substantially higher rates of many major chronic diseases, including circulatory, nervous system, digestive, musculoskeletal, and respiratory diseases..." In his conclusion he stated "...if any veteran has a long-term history of PTSD, especially if this is concurrent with other major psychiatric disorders or inflammatory diseases, such as rheumatoid arthritis, psoriasis, thyroid disease, inflammatory bowel disease, etc., that this veteran has a high risk for developing CVD [cardiovascular disease], including coronary artery disease and myocardial infarction. In addition, as noted, given our current knowledge of the psychobiology of PTSD, veterans with chronic PTSD also are at significant concurrent risk for autoimmune disease." On September 2006 VA outpatient clinic evaluation the Veteran reported a 1999 colonoscopy which revealed two polyps. A barium enema in 2002 was normal. On physical examination bowel sounds were normal; the abdomen was not tender, and there was no organomegaly. There was no assessment of GERD or IBS. On February 2007 VA outpatient clinic evaluation the Veteran was seen for high blood pressure. He reported occasional loose stools after eating sweets, which had persisted for over five years. A September 2007 private progress note by TTP, D.O., lists assessments of high blood pressure, IBS and erectile dysfunction. A February 2008 progress note shows an assessment of IBS. An ultrasound of the abdomen in March 2008 revealed impressions of status post cholecystectomy, and suboptimal visualization of the pancreas and the abdominal aorta due to overlying bowel gas. The rest of the study showed no significant abnormality. On September 2008 VA examination the Veteran reported that he has had a diagnosis of gastroesophageal reflux disease for several years manifested by awakening during the night with choking and coughing or with acid liquid in his throat, sometimes accompanied by a burning sensation in the throat. He stated that he does not generally have epigastric or chest pain. A recent EGD [esophagogastroduodenoscopy] showed a normal esophagus, but he had some irritation of his stomach. He also reported that he had IBS diagnosed in the late 1980's. He indicated that his IBS is manifested by several diarrheal-like bowel movements daily. He stated that he had a cholecystectomy about five years prior and had been treated with cholestyramine. He had not had any worsening of the diarrhea recently. His weight is up and down between 230 and 240 pounds. He had some cramping of the lower abdomen when he needed to have a bowel movement. He had not had any bleeding. The impressions, in pertinent part, were GERD, and IBS possibly aggravated by bile salt irritation of the intestines secondary to cholecystectomy. In an October 2008 addendum to the VA examination report, the examiner noted that he reviewed the letter from Dr. Boscarino regarding his research into the complications of PTSD, alleging that PTSD has been shown to increase the risk of arteriosclerotic heart disease and other diseases, especially inflammatory and autoimmune disorders. He stated, in pertinent part, that the Veteran's GERD and IBS do not fit into any of those categories. He was therefore of the opinion that it is unlikely that the Veteran's GERD and IBS are secondary to his service-connected PTSD. In an undated statement Dr. TTP noted that the Veteran had GERD with erosive gastritis diagnosed, and was taking 20 mg of Omeprazole two times a day. The medication does not control all of his reflux problems. He reported that he cannot sleep on his right side because he will start choking after five to ten minutes and has to roll over on his back or left side. She noted that known causes of GERD with erosive gastritis included stress, excessive alcohol use, (which is known to be caused by depression), and H. pylori (for which the Veteran tested negative). Dr. TTP further stated that the Veteran also had IBS diagnosed, and reported that he had multiple diarrhea-like bowel movements most days and other days had constipation followed by diarrhea the same day. Sometimes he would have constipation for two to three days; he stated that he does not have normal bowel movements any more. Dr. TTP noted that she prescribed cholestyramine twice daily for the Veteran, which caused constipation. She opined that the stresses of PTSD were at least as likely as not causing the Veteran's hypertensive blood pressure with coronary artery disease, GERD, and IBS. On June 2009 VA examination the examiner noted that he reviewed the claims file including the report by Dr. Boscarino regarding his research, the letter from Dr. TTP and his previous examination report of September 2008 with the addenda. He noted that the Veteran has a diagnosis of PTSD that was established in 2006. The Veteran is claiming that his IBS and GERD are caused by, aggravated by, or permanently worsened by his PTSD. He noted that Dr. Boscarino's research indicates that combat Veterans have substantially high rates of many major diseases including circulatory, nervous system, digestive, musculoskeletal, and respiratory problems. However, his research does not specifically address IBS (which is a non-inflammatory bowel disease), or GERD. The examiner stated that he was unaware of any evidence that non-inflammatory bowel disease and GERD are known to be secondary to PTSD. The VA examiner further stated that psychological disorders such as depression and anxiety can certainly aggravate irritable bowel symptoms making them harder to control, but he is not aware of any evidence that it causes the disorder. He stated that GERD is an anatomical abnormality that is unlikely to be secondary to stress. It can be aggravated by medications such as NSAID drugs, which cause hyperacidity and direct GI irritation but not by the medications taken by the Veteran. On the basis of this information, the examiner opined that the Veteran's IBS may be aggravated by his PTSD, although not caused by it and that his GERD is unlikely to be caused or worsened by the PTSD. In a July 2009 addendum to the June 2009 VA examination report the examiner noted that review of the record revealed that the Veteran's diarrhea had been stable for several years and was minimally symptomatic, and that his weight was stable. If the IBS had been worsened by his PTSD, the impact appeared to have been minimal. Pursuant to the January 2012 Board remand, the RO arranged for the Veteran's claims file to be reviewed by an appropriate provider for an advisory medical opinion regarding whether the Veteran's GERD and IBS are related to his episode of bacterial enteritis in service or were caused or aggravated by his service-connected PTSD. In March 2012 VA physician who reviewed the record opined that the Veteran's claimed GERD and IBS are less likely than not caused by PTSD. He stated that his review of online literature on each disorder (including from "Up To Date" as well as the "Mayo Clinic") found specifically that IBS is "NOT" caused by PTSD. The physician explained further, in essence, that the etiological factors for GERD are those with a direct effect on the gastroesophageal sphincter. PTSD (of itself) would not have a direct affect on the sphincter and therefore would not directly cause GERD. Certain medications for PTSD can affect the sphincter causing GERD; however, on review of the Veteran's records, there were no direct complaints of GERD associated with the Veteran's medication treatment of his PTSD (which would be needed to directly associate GERD with the medications). As such was not found, GERD would have to be assumed secondary to another etiology. This holds true for aggravation of GERD and IBS as well since there are no direct complaints of aggravation of IBS or GERD associated with treatment for PTSD or related to complaints of PTSD (on review of the many notes in the Veteran's [medical] records). Furthermore, the Veteran had not identified any medications for PTSD as being associated with GERD and IBS. The consulting VA physician stated a review of the medical literature revealed that aggravation of GERD and IBS has a multitude of triggers; and without direct evidence to show of aggravation stemming from a [PTSD-medication related] trigger it would be pure speculation to assume that either gastrointestinal condition was aggravated by PTSD. Regarding GERD, the Veteran had a 5-year history without triggers [for symptoms] identified. He takes Prilosec for GERD, and has no upper gastrointestinal symptoms on medications. Regarding the enteritis during active military duty, it was noted to be an isolated classic acute viral upper gastrointestinal infection; and upon review of [online pertinent] literature, is "NOT" a cause of IBS or GERD and would not cause long term chronic problems or aggravation since it is self limited. PTSD stressors have been felt by many to aggravate gastrointestinal complaints, such as those the Veteran claims. However, the Veteran noted that his PTSD was stable on medication and specifically did not identify stress and anxiety as triggering his symptoms. Instead, the Veteran identified "sweets" as a trigger for his IBS symptoms (noted in 2006 upon entry into primary care). The Veteran related he had had IBS for 6 years, with alternating constipation and diarrhea. He did not take medications for IBS. He denied triggers other than "sweets". His complaints were noted shortly following gallbladder surgery a few years back (and that could certainly play a role with his present lower gastrointestinal symptoms). VA medical advisor concluded that therefore he did not feel that the Veteran's GERD and IBS were caused by or aggravated by PTSD. 1. GERD To support his claim of service connection for GERD as secondary to his service-connected PTSD, the Veteran submitted reports of medical research by Dr. Boscarino who found that PTSD-positive Veterans had substantially higher rates of many major chronic diseases, including digestive diseases. The United Stated Court of Appeals for Veterans Claims (Court) has held that while a medical article or treatise can provide support for a claim, it must be combined with an opinion by medical professional and reflect the specific facts of a case, as opposed to a discussion of generic relationships. See Sacks v. West, 11 Vet. App. 314, 316-17 (1998). Here, while Dr. Boscarino's medical research is specific to "PTSD-positive Veterans," it does not specifically discuss the Veteran's case, and is not accompanied by any medical opinion of a medical professional which directly supports the contentions which the Veteran has raised. The Board observes that the June 2009 VA examiner noted that Dr. Boscarino's research does not specifically address GERD. That examiner (in an October 2008 addendum to an earlier examination report) had opined that it is unlikely that the Veteran's GERD is secondary to his service-connected PTSD. The examiner explained that GERD is an anatomical abnormality that is unlikely to be secondary to stress. It can be aggravated by medications such as NSAID [nonsteroidal anti-inflammatory drug], which cause hyperacidity and direct GI irritation (but not by the medications taken by the Veteran). Based on that information, it was his opinion that the Veteran's GERD is unlikely to be caused or worsened by his PTSD. This opinion by VA examiner, based upon a thorough claims file review (and an awareness of the Veteran's complete medical history), and accompanied by an explanation of rationale, is of considerable probative value and weighs heavily against the Veteran's claim. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Furthermore, in March 2012 a VA consulting physician who reviewed the record and medical literature, opined that GERD is less likely than not caused or aggravated by PTSD. He noted that enteritis shown in service was an isolated classic acute viral upper gastrointestinal infection and the literature shows that it is not a cause of GERD and would not cause long term chronic problems or aggravation since it is self limited. In addition, he noted that while certain medications for PTSD can affect the sphincter causing GERD, the Veteran had not complained of GERD associated with the medication treatment he receives. The Veteran stated that his PTSD was stable on medications and he did not specifically identify stress and anxiety as triggering any symptoms of GERD. The medical evidence in support of the Veteran's claim is the statement by Dr. TTP. She explained that noted stress is among the main causes of GERD with erosive gastritis. She opined that the stresses of the Veteran's PTSD are at least as likely as not causing the Veteran's GERD. However, she does not cite to clinical data that support her conclusion. This is particularly significant in light of the VA consulting provider's opinion that GERD is caused and triggered by factors which impact on the gastroesophageal sphincter. Dr. TTP does not address the observation that PTSD is not among such factors. The Veteran's own lay opinion in this matter is not probative evidence. He is a layperson, and lacks the training to offer an opinion regarding the etiology of GERD. That is a complex medical question that requires medical expertise. See Jandreau v. Nicholson, 492 F3d. 1372 (Fed. Cir. 2007). As is noted above, the opinions he has presented in support are outweighed in probative value by the opinions against his claim. In light of the foregoing, the Board concludes that the preponderance of the evidence is against this claim. Accordingly, service connection for GERD, to include as secondary to service-connected PTSD, must be denied. 2. IBS As was noted above, it is neither shown nor alleged that the Veteran's IBS is directly related to his service. He contends that his IBS is secondary to his service-connected PTSD. There are conflicting medical opinions as to whether the Veteran's claimed IBS is secondary to his PTSD. The evidence shows that IBS was diagnosed in the late 1980's. In an October 2008 addendum, a September 2008 VA examiner opined that it was unlikely that the Veteran's IBS is secondary to his service-connected PTSD. Conversely, the Veteran's private physician, Dr. TTP, opined that the stresses of PTSD are at least as likely as not causing the Veteran's IBS. Additionally, in June 2009 the September 2008 VA examiner (upon review of the entire record) stated that psychological disorders such as depression and anxiety can certainly aggravate IBS symptoms making them harder to control, but that he was unaware of evidence that it causes IBS. Because the various opinions were either stated in speculative terms or were unaccompanied by adequate explanation of rationale, the Board sought further medical guidance to resolve the question of whether the Veteran's PTSD aggravated his IBS. In March 2012 a VA consulting physician opined that the IBS is less likely than not caused by PTSD. He stated that he reviewed online medical research vehicles, to include "Up to Date" and "Mayo Clinic" and that the literature found specifically states that IBS is not caused by PTSD. He stated further that he found no direct complaints by the Veteran of aggravation of IBS associated with treatment of PTSD or related complaints of PTSD. The record shows that the Veteran was questioned and did not identify medications for PTSD as being associated with IBS. He noted that upon review of the medical literature, aggravation of IBS has a multitude of triggers; and without direct evidence of a PTSD/PTSD medication-related trigger resulting in aggravation, it would be pure speculation to assume that IBS was aggravated [by PTSD] in light of the multitude of triggers. The Veteran had noted that his PTSD was stable on medication and did not identify stress and anxiety as triggering IBS symptoms. Instead, he related "sweets" as a noted trigger for his IBS (noted in 2006 upon entry into primary care). The consulting VA physician also noted that the Veteran's IBS complaints seemed to have been more noticeable shortly following gallbladder surgery, and that that could certainly have played a role with the present lower gastrointestinal symptoms. The VA medical advisor concluded that based on the foregoing, IBS was not caused by or aggravated by PTSD. He acknowledged that symptoms of PTSD can aggravate IBS but found no evidence in the record that such occurred in the instant case. The Board finds the March 2012 opinion by a VA consulting physician to be probative and persuasive. It is by a medical professional competent to provide it who expresses familiarity with the record and explains the rationale in detail, with cites to the clinical record and references to medical literature The Board acknowledges that the June 2009 VA examiner opined that the Veteran's IBS may be aggravated by his PTSD. That opinion is in speculative terms and lacks probative value. A subsequent opinion to that effect in a July 2009 addendum ( if the Veteran's IBS had been worsened by his PTSD, the impact appeared to have been minimal) is likewise in speculative terms. See Bloom v. West, 12 Vet. App. 185, 187 (1999) On VA examination in September 2008 the examiner found that the Veteran's IBS was possibly aggravated by bile salt irritation of the intestines secondary to his cholecystectomy (identifying a nonservice-connected etiological factor). Such opinion does not support the Veteran's claim. The opinion by the Veteran's private physician, Dr. TTP that his IBS is aggravated by his service-connected PTSD merits little probative value. The opinion is unaccompanied by adequate explanation of rationale; it does not cite to supporting clinical data, and is conclusory. While the Veteran may sincerely believe his IBS is related to or was aggravated by his service-connected PTSD, he is a layperson, and his opinion is not competent evidence in a medical matter such nexus between PTSD and IBS. See Jandreau, 492 F3d. 1372. In light of the foregoing, the Board concludes that the preponderance of the evidence is against this claim. Accordingly, service connection for IBS, to include as secondary to service-connected PTSD must be denied. ORDER Service connection for GERD, to include as secondary to service-connected PTSD, is denied. Service connection for IBS, to include as secondary to service-connected PTSD, is denied. ____________________________________________ GEORGE R. SENYK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs