Citation Nr: 1315674 Decision Date: 05/13/13 Archive Date: 05/15/13 DOCKET NO. 08-15 725 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for a chronic liver disability. REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The Veteran served on active duty from June 1965 until his retirement in October 1987. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2006 rating decision by the Montgomery Regional Office (RO) of the Department of Veterans Affairs (VA). In June 2010, a Travel Board hearing was held before an Acting Veterans Law Judge who is presently no longer employed by the Board. Pursuant to 38 C.F.R. § 20.707, the Veteran provided testimony at another travel Board hearing before the Undersigned in June 2011. A transcript of the hearing has been associated with the claims files. In February 2012, the case was remanded for further development. The appeal is once again REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran received a liver transplant in March 2005 at the Mayo Clinic. The liver disease was assigned diagnoses of cryptogenic cirrhosis, as well as alcoholic cirrhosis with heterozygosity to alpha-1 antitrypsin deficiency. The Veteran has predominantly alleged that his liver disability is related to the medication, Aldomet, which was prescribed to him for hypertension during service, and which he claims caused elevation of his liver enzymes during service. He has also more generally alleged that he was exposed to asbestos, herbicides, including Agent Orange (from service in Vietnam), experimental anti-malaria drugs during Vietnam service (See June 2011 Hearing Transcript, page 17) and numerous other chemicals, including benzene, toluene and trichloroethylene, some or all of which may have harmed his liver. Additionally, he has reported that he became ill while stationed in Korea with symptoms of vomiting blood, nose bleeds and bloody stools (and was told at the time that he may have had a small ulcer) and that he became sick while stationed in Egypt, possibly due to exposure to ticks or other parasites. He has reported that although he drank daily to a moderate degree (i.e. 2 to 3 drinks per night) for a large part of his adult life and the bulk of his military career, prior to permanently abstaining from drinking in August 2004, he never experienced any legal, job or social problems due to alcohol. (See e.g., January 2005 Mayo Clinic Alcohol Psychiatry Addiction Counseling note). The record also indicates that when assessed in August 2005, the Veteran was not found to meet the DSM-IV criteria for any substance related disorder. (See August 2012 Synopsis of Army Substance Abuse Program Assessment Activities). The service treatment records do show that the Veteran experienced elevated liver enzymes (LFTs) as early as May 1978 and that the elevated enzymes were found to be "probably secondary to taking Aldomet." The medication was discontinued in May 1978 but the Veteran was subsequently found to have abnormal LFTs in November 1978. In April 1981, it was noted that the Veteran's SGOT level had returned to normal while abstaining from alcohol. However, in October 1985, the Veteran was found to generally have an "abnormal hematologic picture that could have possibly been from alcohol use." Findings included an SGOT level of 56 and an SGTP level of 48 (within a range where normal is up to 50). Subsequently, at his August 1987 retirement examination, the Veteran's abdomen and viscera were found to be normal and on his report of medical history at separation, he did not report any stomach liver or intestinal trouble or jaundice or hepatitis. The records also show occasional gastrointestinal symptomatology, including in December 1974 (vomiting blood), February 1975 (diarrhea attributed to viral syndrome) and October 1981 (diarrhea while stationed in Cairo). The post-service medical evidence of record shows an elevated SGOT finding of 61 in June 1995 and an elevated SGOT finding of 107 in September 1997. The Veteran was again found to have elevated liver enzymes in May 2002 (at which point he reported that the enzymes had been elevated for the past 20 years). In June 2002, he was diagnosed with thrombocytopenia without significant bleeding. In December 2002, he was afforded a VA examination where he was diagnosed with cirrhosis with portal hypertension, probably due to alcohol and decreased platelet counts (Banti syndrome). Subsequently, a liver biopsy was performed, which confirmed this diagnosis, and his condition worsened to the point of requiring the liver transplant. As the Veteran clearly has current liver disease; as the evidence shows that the he did take at least one medication during service that could potentially cause liver problems (i.e. Aldomet), accompanied by contemporaneous abnormal liver enzyme findings; and as the Veteran has also credibly testified to some level of exposure to hazardous chemicals and materials during service, the Board finds that a VA examination, with appropriate review of the claims file, to assess the likely etiology of the current liver disease, is necessary prior to final adjudication of this claim. 38 C.F.R. § 3.159(c)(4). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA liver examination with a physician knowledgeable in liver disorders. The purpose of the examination is to determine whether the Veteran's current liver disability is related to service. The claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. With respect to the review of the claims file, the Board calls the examiner's attention to the following: A) The short summary of the evidence contained in the Board's most recent May 2013 remand. B) The service treatment records, including the findings of elevated liver enzymes as early as May 1978. C) The post-service medical evidence, including findings of elevated liver enzymes in June 1995 and September 1997, findings of actual liver disease as early as June 2002, the December 2002 VA examination report, the records of the subsequent treatment for liver disease leading up to the March 2005 liver transplant, including the January 2005 Mayo Clinic Alcohol Psychiatry Addiction Counseling note documenting the Veteran's history of alcohol use, and any pertinent post-transplant private or VA treatment records. D) The Veteran's assertions, including a March 2004 notice of disagreement, a January 2007 notice of disagreement and a May 2008 Form 9; statements from May 2004, October 2005, January 2007, June 2010, June 2011, March 2012, August 2012 and December 2012; and the Veteran's June 2010 and July 2011 hearing testimony. E) Any other information in the claims file that the examiner deems pertinent. The examiner should then provide an opinion as to whether it is at least as likely as not (i.e. a 50% chance or greater) that the Veteran's current liver disease began in service, or is otherwise related to service, including to the in-service alcohol use; the taking of Aldomet or other prescription medication (to include anti-malaria drugs); exposure to hazardous chemicals (to include Agent Orange and other herbicides, benzene, toluene and trichloroethylene); and the gastrointestinal symptomatology experienced by the Veteran during service (including the illnesses experienced while stationed in Korea and Egypt). The Veteran's assertions should be addressed by the examiner. The examiner must provide a complete explanation for his or her opinion, based on his or her clinical experience, medical expertise, and established medical principles. 2. The RO/AMC must notify the Veteran that it is his responsibility to report for the above examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination or to fully cooperate with the examiner without good cause could include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2011). In the event that the Veteran does not report for the aforementioned examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 3. After the examination has been completed, the RO/AMC must review the examination report to ensure that it is in compliance with the remand instructions. If the report does not include an opinion appropriately responsive to the remand instructions, it must be returned to the providing examiner for corrective action. 4. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran must be provided with a Supplemental Statement of the Case and be afforded reasonable opportunity to respond. The case must then be returned to the Board for further appellate review, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that is remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ ROBERT E. O'BRIEN Acting Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).