Citation Nr: 1320577 Decision Date: 06/26/13 Archive Date: 07/05/13 DOCKET NO. 10-34 735 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for resection of the colon/removal of the entire rectum. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD D. Rogers, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1967 to August 1970 and from June 1971 to June 1974. This case comes before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan, which denied entitlement to the benefit sought on appeal. In the March 2013 Written Brief Presentation, the Veteran's representative indicated that the Veteran wished to waive initial RO consideration of any newly submitted evidence following the issuance of the statement of the case in August 2010. See 38 C.F.R. § 20.1304 (2012). In May 2013, the Veteran withdrew his request for a Central Office Board hearing pertaining to the issue decided herein. See 38 C.F.R. § 20.704. A review of the Veteran's virtual VA electronic claims file is significant for a March 2013 RO congressional inquiry response as to the status of the Veteran's claims, which indicates that additional claims for service connection for left and right parastomal hernias and for a temporary total evaluation for surgical treatment of a hernia with convalescence are currently pending adjudication at the RO. Correspondence received from the Veteran in August 2012 raises a claim for entitlement special monthly compensation (his statements of record show that SMC has been requested under 38 U.S.C. § 1114(s) for total plus 60 percent, 38 U.S.C. § 1114(o) by analogy due to loss of anal sphincter control resulting from removal of his rectum, and 38 U.S.C. § 1114(k) for loss of use of a creative organ by analogy for loss and loss of use of his colon and rectum organs related to residuals of his service-connected ulcerative colitis with ileostomy and total colectomy). In addition, correspondence received in March 2013 raises the issue of entitlement to service connection for type II diabetes mellitus associated with herbicide exposure. There is no indication that these issues have been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. In a July 1975 rating decision, service connection was granted for ulcerative colitis and staged evaluations were assigned under 38 C.F.R. § 4.114, Diagnostic Code 7323 (ulcerative colitis), effective June 14, 1974. 2. In a May 1985 rating decision, a 100 percent schedular evaluation was assigned under 38 C.F.R. § 4.114, Diagnostic Code 7323-7333 for ulcerative colitis with ileostomy and total colectomy, effective December 14, 1984. 3. Resection of the colon and removal of the entire rectum is service-connected as part and parcel of the Veteran's service-connected ulcerative colitis with ileostomy and total colectomy. CONCLUSION OF LAW Service connection is in effect for resection of the colon/removal of the entire rectum; the issue is moot. 38 U.S.C.A. §§ 1110, 1155, 7105 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 4.114, Diagnostic Code 7323-7333 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. 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, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that 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 the Veteran). Duties to Notify and Assist In correspondence dated in August 2009, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2012). Specifically, the RO notified the Veteran of: information and evidence necessary to substantiate the claim for service connection; information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. The letter also notified the Veteran of the process by which disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was able to participate effectively in the processing of his claim. VA has done everything reasonably possible to assist the Veteran with respect to his claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). The Veteran's service records and identified post-service VA and private treatment records have been associated with the claims file. All identified and available treatment records have been secured. The Board acknowledges that the Veteran has not been afforded a VA examination to determine the nature and etiology of the claimed disability. The Board finds, however, that a remand for obtainment of a VA examination and/or medical opinion is not necessary in this case given the finding herein and discussed in further detail below that that service connection for the claimed disability currently is and has been in effect since 1984, more than 20 years prior to the date the claim decided herein was received. Indeed, medical records undoubtedly indicate that the Veteran underwent resection of his colon and removal of his entire rectum when a total proctocolectomy and ileostomy was performed for treatment of his service-connected ulcerative colitis in February 1985. Additionally, the Veteran has submitted medical literature which provides overviews of the surgical procedures performed and any associated effects related such procedures. Under these circumstances, VA has no duty to obtain further medical examinations and/or opinions pertaining to the claim. 38 C.F.R. § 3.159. The Board acknowledges that the August 2009 letter did not address service connection claimed secondary to service-connected disability. Notwithstanding, however, correspondence received from the Veteran, who is a retired (June 2012) County Veteran Service Officer of 20 years, and his representative is demonstrative that they have actual knowledge as to the information and evidence necessary to substantiate the claim decided herein. For the foregoing reasons, it is not prejudicial to the appellant for the Board to proceed to a final decision in this appeal. Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 494-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). In relevant part, 38 U.S.C.A. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). The Veteran is competent to report what the Veteran can observe and feel through the senses. See Layno v. Brown, 6 Vet. App. 465 (1994). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, 6 Vet. App. at 465 (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the Federal Circuit, citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. at 511. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a non service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). 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; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Competent lay evidence may establish the presence of observable symptomatology and, in certain circumstances, it may provide a basis for establishing service connection. See Barr, 21 Vet. App. at 303. Although claimants may be competent to provide the diagnoses of simple conditions, such as a broken leg, they are not competent to provide evidence on more complex medical questions beyond simple observations. Jandreau, 492 F.3d at 1377; see Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a veteran's lay belief that his schizophrenia aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue). Even if lay testimony is competent, should VA find it to be mistaken or lacking credibility, the Board may reject it as unpersuasive. Buchanan, 451 F.3d at 1331. The Board may find a lack of credibility in, for example, conflicting medical statements or witness biases. Id. at 1337. The lack of contemporaneous medical evidence is also relevant; however, the mere lack of such evidence may not constitute the sole basis for discrediting the lay evidence. Id. Factual Background The Veteran contends that service connection is warranted for resection of his colon and removal of his entire rectum during his 1985 surgery for treatment of his service-connected ulcerative colitis. He claims that his 1985 surgical treatment has resulted in complete loss of sphincter control of his rectum and anus as contemplated under Diagnostic Code 7332, and stricture of his rectum and anus requiring ileostomy which he claims should be contemplated by analogy under Diagnostic Code 7333 (for stricture of his rectum and anus requiring colectomy). He stated that an ileostomy is essentially the same as a colectomy, however, it pertains to the small intestine verses the large intestine. He has stated that the only Diagnostic Code pertaining to the small intestine is for resection of the small intestine, which is contemplated under Diagnostic Code 7328. He claims that the 100 percent evaluation in effect since December 1984 under Diagnostic Code 7323-7333 does not consider, contemplate, or adequately compensate him for the necessity of having a permanent ileostomy, which presents problems and disability separate from and in addition to what is contemplated by the 100 percent evaluation currently in effect. Historically, in a July 1975 rating decision, service connection was granted for ulcerative colitis and staged evaluations were assigned under 38 C.F.R. § 4.114, which governed the schedule of ratings of the digestive system, Diagnostic Code 7323, for evaluation of ulcerative colitis. The evidence of record at that time showed that the Veteran began receiving treatment for ulcerating colitis manifested by symptoms of frequent cramping and diarrhea during active service in May 1973. Prior to December 1984, the Veteran experienced intermittent flare-ups of ulcerative colitis necessitating inpatient treatment. In October 1980, sigmoidscopy revealed the presence of a lesion in the rectal sigmoid area and biopsy confirmed a diagnosis of ulcerative colitis. Barium enema showed boggy adenitis mucosa and colonoscopy revealed atrophic and friable mucosa compact with active proctitis of the first 10 to 12 centimeters of the rectum. His symptoms included abdominal cramping, diarrhea, rectal bleeding, and mucous in his stool which was clay-like consistency and were treated primarily with steroids, Sulfasalazine, and use of systemic steroids were required on a few occasions. From December 1984 to February 1985, the Veteran received frequent inpatient treatment for his service-connected ulcerative colitis due to symptoms of abdominal pain, rectal pain, nausea and vomiting after eating, infrequent light brown soft stools with occasional blood until developing constipation on the day of admission, and a 30 pound weight loss during a 2 month period. In February 1985, the Veteran's ulcerative colitis with bleeding was unresponsive to medical treatment. Consequently, a total proctocolectomy and ileostomy were performed. 12 days later, an emergency exploratory laparotomy, lysis of adhesions, ileostomy revision, and disimpaction of fibroid material in the ileum were required due to formation of a small bowel obstruction secondary to fibroid material in the ileum, probably due to Metamucil. In a May 1985 rating decision, due to a finding that the evidence was reflective of a permanent worsening in the Veteran's ulcerative colitis beginning December 14, 1984, a schedular 100 percent evaluation was assigned effective that date under Diagnostic Code 7323-7333 for ulcerative colitis with ileostomy and total colectomy. Thereafter, additional surgical treatment was required in 1992 for a small bowel obstruction most likely due to adhesions from his previous 1985 surgery. Cauterization of his stoma has also been required to stop bleeding associated with injury of his stoma. Also, during the pendency of this claim, the Veteran has submitted additional claims for service connection with medical evidence showing surgical treatment for a hernia of his right stoma which required relocation to his left side and closure of his right stoma in April 2012. A VA abdominal CT scan dated in December 2013 further shows formation of a hernia of his newly created left stoma. As noted above, the Veteran has submitted separate claims for service connection for hernias of his right and left stomas, thus, these claims will not be addressed herein, however, the Board acknowledges the Veteran's statements indicating that the associated medical evidence supports his contention that his ileostomy presents additional disability which is not considered, contemplated by, or addressed by the 100 percent evaluation in effect for his service-connected ulcerative colitis with ileostomy and total colectomy. In February 2007, the Veteran underwent a VA QTC examination in connection with his claim for special monthly compensation base on being housebound. The examiner noted that the Veteran did not claim to be housebound at that time, rather, he was requesting special monthly compensation due to the constant presence of an ileostomy bag with occasional bouts of diarrhea through the ileostomy requiring extra care and attention of the bag. The examiner felt that the Veteran should qualify for additional compensation since he has an ileostomy bag that requires regular care and because he does not have good control over his bowel movements, Analysis Having reviewed the evidence of record, the Board finds that separation service connection resection of the colon and removal of the entire rectum from the Veteran's currently service-connected ulcerative colitis with ileostomy and total colectomy is not warranted. Essentially, the weight of the medical evidence indicates that the Veteran's conditions of resection of his colon and removal of his entire rectum are manifestations of his currently service-connected ulcerative colitis with ileostomy and total colectomy. Indeed, the Veteran has consistently reported, and as indicated by the preponderance of the medical evidence, that his current symptoms stem from his service-connected ulcerative colitis, which required subsequent surgical treatment in 1985 with a total proctocolectomy and ileostomy. Regarding the Veteran's 1985 surgical treatment for ulcerative colitis, whereby a total proctocolectomy and ileostomy were performed, an electronic research article submitted by the Veteran, entitled Proctocolectomy and Ileostomy for Irritable Bowel Syndrome - Surgical Overview, details what his surgical treatment entailed. The article indicates that during a proctocolectomy and ileostomy, the large intestine and rectum are removed, leaving the lower end of the small intestine (ileum). The anus is sewn closed and a small opening is made in the skin of the lower abdomen (stoma). The surgical procedure to create an opening is an ostomy. The ileum is connected to the stoma, creating an opening to the outside of the body. The surgical procedure to create the opening in the intestine is called an ileostomy. Stool empties into a small plastic pouch (ostomy bag), that is applied to the skin around the stoma, which must be changed several times a day. Another article submitted by the Veteran, entitled What is an Ileostomy, indicates that an ileostomy can be permanent, as in the Veteran's case, or temporary depending on the reason for the surgery. It explained that an ileostomy is round or oval in shape, and because there is no nerve supply or muscle involved, it is not voluntarily controlled. As noted above, prior to the May 1985 rating decision, the Veteran's service-connected ulcerative colitis was evaluated solely under Diagnostic 7323, for evaluation of ulcerative colitis. In the May 1985 rating decision, a 100 percent disability rating was assigned, effective December 14, 1984, under Diagnostic Code 7323-7333 for "ulcerative colitis with ileostomy and total colectomy." The Board notes that Diagnostic Code 7323 pertains to ulcerative colitis, and Diagnostic Code 7333 pertains to stricture of the rectum and anus. In this regard, 38 C.F.R. § 4.27 explains that diagnostic code numbers appearing opposite the listed ratable disabilities are arbitrary numbers for the purpose of showing the basis of the evaluation assigned and for statistical analysis in the VA, which extend from 5000 to 9999. Great care will be exercised in the selection of the applicable code number and in its citation on the rating sheet. No other numbers than listed or furnished are to be employed for rating purposes, with an exception as to unlisted conditions. When assigning a diagnostic code number to a disease, when an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" as follows: the first 2 digits will be selected from that part of the schedule most closely identifying the part, or system, of the body involved; the last 2 digits will be "99" for all unlisted conditions. With diseases, preference is given to the number assigned to the disease itself. If the assigned rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27. Accordingly, in this case, the assignment of the schedular 100 percent evaluation in the 1985 rating decision, which remains currently in effect, is reflective of an evaluation for stricture of the rectum and anus requiring colostomy as a residual condition of the Veteran's service-connected ulcerative colitis. Given that Veteran's entire colon or large intestine was removed during the 1985 surgery, a separate disability evaluation is and was no longer warranted for ulcerative colitis under Diagnostic Code 7323 as alleged by the Veteran's representative in a November 2010 statement. The disability rating in effect prior to the May 1985 rating decision for the Veteran's service-connected ulcerative colitis under Diagnostic Code 7323, which is a disease or disability of the colon (emphasis added) is no longer warranted. Since the Veteran's colon was removed during the 1985 surgery, it cannot possibly be said that he currently has an additional disease or disability (i.e., ulcerative colitis) of his colon. Thus, a disability rating cannot be assigned for disease of the disability of the colon which the Veteran no longer has and a separate disability rating for removal of the colon in addition to a disability rating for ulcerative colitis is not warranted. The Board also finds that the 100 percent disability rating assigned and currently in effect under Diagnostic Code 7232-7333 for "ulcerative colitis with ileostomy and total colectomy," also contemplates and adequately compensates the Veteran for resection of his colon and removal of his entire rectum. Specifically, as noted above, the 100 percent evaluation currently in effect was assigned under Diagnostic Code 7333 for stricture of the rectum and anus as a residual condition of the Veteran's ulcerative colitis. The term "stricture" means stenosis. The term "stenosis" means an abnormal narrowing of a duct or canal; called also arctation, coarctation, and stricture. Dorland's Illustrated Medical Dictionary, 1811, 1795 (31st ed. 2007). Thus, Diagnostic Code 7333 necessarily contemplates, abnormal narrowing of the Veteran's rectum and anus as his rectum was surgically removed and his anus was surgically closed during the 1985 surgery. Moreover, as in this case, a 100 percent disability evaluation is assigned for stricture of the rectum and anus requiring colostomy. The term "colostomy" refers to surgical creation of an opening between the colon (large intestine) and the surface of the body. Dorland's Illustrated Medical Dictionary, 394 (31st ed. 2007). As indicated by the evidence of record and the Veteran's own statements, a colostomy and an ileostomy are essentially the same, however, an ileostomy as in this case, involves surgical creation of an opening between the small intestine and the surface of the body for removal of bodily waste. The Veteran essentially has essentially agued that an additional rating is warranted by analogy under Diagnostic 7333 for stricture of his rectum and anus requiring ileostomy. Board finds, however, that the 100 percent evaluation currently in effect under Diagnostic Code 7333, was indeed assigned for his ileostomy as claimed in the current appeal. Indeed, his colon was removed during surgery in 1985, thus, surgical creation of an opening between the colon and the surface of the body (i.e., colostomy) could not have been performed. It necessarily follows, then, that the 100 percent evaluation currently in effect under Diagnostic Code 7333 was assigned for stricture of his rectum and anus requiring ileostomy. Thus, for the reasons explained above, the Board finds that to the extent that resection of the colon and removal of the entire rectum have been complained of or otherwise documented, it is part and parcel to the Veteran's service-connected ulcerative colitis with ileostomy and total colectomy. Accordingly, service connection is not warranted on an independent basis in this case for resection of the colon and removal of the entire rectum. The Board acknowledges the Veteran's assertion that the aforementioned opinion of the 2007 VA QTC examiner supports his claim for additional compensation. The Board disagrees. Specifically, the examiner essentially opined that the Veteran's disability should qualify for additional compensation due to lack of control of his bowel movements and the constant presence of an ileostomy bag, which requires extra care and attention at times. To the contrary, however, as explained above, the currently assigned 100 percent evaluation contemplates the presence of the Veteran's ileostomy and bag. In this regard, the medical examiner is competent to opine as to medical matters, he or she is not competent to opine as to legal matters such as the application of the rating schedule to the facts of the this particular case. 38 C.F.R. § 3.159(a). Accordingly, the opinion of the 2007 examiner is accorded no probative value as to whether service connection is warranted for resection of the colon and removal of the entire rectum. It is important to recognize that the Veteran may not be entitled to double compensation for the same disability. The evaluation of the same disability under various diagnoses is to be avoided, as is the evaluation of the same manifestation under different diagnoses. 38 C.F.R. 4.14; Esteban v. Brown, 6 Vet. App. 259, 261 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). The rationale behind this "rule against pyramiding" is that a claimant should not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). Absent evidence of resection of the colon and removal of the entire rectum with distinct symptomatology from his service-connected ulcerative colitis with ileostomy and total colectomy, consideration of service connection for resection of the colon and removal of the entire rectum based on the same manifestations and symptomatology not warranted. Such an action would amount to impermissible pyramiding. Therefore, absent a clear distinction between the Veteran's current symptoms and those for which compensation is already in effect for, which includes his ileostomy and associated problems, service connection for resection of the colon and removal of the entire rectum is not warranted as such an award would be duplicative of his already service-connected ulcerative colitis with ileostomy and total colectomy. Accordingly, the Board finds that the claim of entitlement to service connection for resection of the colon and removal of the entire rectum must be dismissed because service connection has already been established for left ulcerative colitis with ileostomy and total colectomy based on the same currently manifested symptomatology. 38 U.S.C.A. § 7105. ORDER As service connection for ulcerative colitis with ileostomy and total colectomy is already in effect, the appeal on the issue of entitlement to service connection for resection of the colon and removal of the entire rectum based on the same manifestations and symptoms is dismissed. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs