Citation Nr: 1322206 Decision Date: 07/11/13 Archive Date: 07/18/13 DOCKET NO. 07-38 930 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for a gastrointestinal disability, to include gastroesophageal reflux disease (GERD) and a hiatal hernia, including as due to herbicide exposure. REPRESENTATION Appellant represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from October 1969 to October 1971, including in combat in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which denied, in pertinent part, the Veteran's claim of service connection for a gastrointestinal disability, to include GERD and a hiatal hernia (which was characterized as GERD and a hiatal hernia). The Board notes that the Veteran has contended that he incurred GERD as a result of in-service herbicide exposure while on active combat service in Vietnam. Having reviewed the evidence of record, including the Veteran's lay statements, the Board finds that the issue on appeal is characterized more appropriately as stated on the title page of this decision. See also Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004), and Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001) (explaining that the Board must consider all potential theories of entitlement raised by the evidence). In August 2009 and in March 2011, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington, DC, for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. In its August 2009 remand, the Board directed the RO/AMC to attempt to obtain the Veteran's updated VA and private treatment records and schedule him for an examination to determine the nature and etiology of his gastrointestinal disability. These records subsequently were obtained by the RO/AMC. The Veteran failed to report for his VA examination when it was scheduled in June 2010. In its March 2011 remand, the Board directed the RO/AMC to attempt to obtain additional treatment records and to provide the Veteran with appropriate notice concerning any inability to obtain these records. The RO/AMC attempted to obtain additional treatment records and, when VA received a negative response concerning these records, the Veteran was notified appropriately. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). FINDINGS OF FACT 1. The record evidence shows that the Veteran served in combat in the Republic of Vietnam between July 1970 and April 1971; thus, his in-service herbicide exposure is presumed. 2. Without good cause, the Veteran failed to report for VA examination in June 2010 scheduled for the purpose of determining the nature and etiology of his gastrointestinal disability. 3. The preponderance of the competent probative evidence of record demonstrates that the Veteran's current gastrointestinal disability is not related to active service or any incident of service. CONCLUSION OF LAW A gastrointestinal disability, to include GERD and a hiatal hernia, was not incurred in or aggravated by active service, including as due to herbicide exposure. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 1154, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.655 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. In a letter issued in May 2006, VA notified the Veteran of the information and evidence needed to substantiate and complete his claim, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). This letter informed the Veteran to submit medical evidence relating the claimed disability to active service and noted other types of evidence the Veteran could submit in support of his claim. The Veteran also was informed of when and where to send the evidence. After consideration of the contents of this letter, the Board finds that VA has satisfied substantially the requirement that the Veteran be advised to submit any additional information in support of his claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Notice of the five elements of a service-connection claim was provided in the May 2006 VCAA notice letter, as is now required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). As will be explained below in greater detail, the evidence does not support granting service connection for a gastrointestinal disability. Because the Veteran was fully informed of the evidence needed to substantiate this claim, any failure of the RO to notify the Veteran under the VCAA cannot be considered prejudicial. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The Veteran also has had the opportunity to submit additional argument and evidence and to participate meaningfully in the adjudication process. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). With respect to the timing of the notice, the Board points out that the Court has held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a Veteran before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the May 2006 VCAA notice letter was issued prior to the currently appealed rating decision issued in October 2006. Because the Veteran's claim is being denied in this decision, any question as to the appropriate disability rating or effective date is moot. See Dingess, 19 Vet. App. at 473. And any defect in the timing or content of the notice provided to the Veteran and his service representative has not affected the fairness of the adjudication. See Mayfield, 444 F.3d at 1328. The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the RO and the Board, although he declined to do so. It appears that all known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The Veteran's Virtual VA claims file has been reviewed and no relevant evidence was located there. The Veteran also does not contend, and the evidence does not show, that he is in receipt of Social Security Administration (SSA) disability benefits such that a remand to obtain his SSA records is required. The Veteran has contended that he was treated for a gastrointestinal disability at Unity Health Center in Shawnee, Oklahoma, in approximately November 1984. He also has contended that he was treated for a gastrointestinal disability at the VA Medical Center (VAMC) in Fayetteville, Arkansas between January 1990 and December 1995. In response to requests from the RO for these records, Unity Health Center notified VA in March 2010 and in November 2011 that the Veteran was not treated at that facility in November 1984 and it no longer kept records dating back to 1984. Similarly, the VAMC in Fayetteville, Arkansas, notified the RO in January 2007 and in February 2010 that there were no records for the Veteran at that facility. (The Board notes parenthetically that it appears that the Veteran has contended that he was treated at the VAMC in Fayetteville, North Carolina, rather than at the VAMC in Fayetteville, Arkansas, for his gastrointestinal disability. A review of the claims file shows that, in response to a request for the Veteran's treatment records, the VAMC in Fayetteville, North Carolina, notified the RO in January 2010 that these records had been transferred to the VAMC in Atlanta, Georgia. The VAMC in Atlanta, Georgia, subsequently provided all of the Veteran's records from the VAMC in Fayetteville, North Carolina, that were in its possession and these records are included in the Veteran's claims file.) In cases where the Veteran's service treatment records (or other pertinent records, for that matter) are unavailable through no fault of the claimant, there is a heightened obligation to assist the claimant in the development of his or her case. O'Hare v. Derwinski, 1 Vet. App. 365 (1991). VA must provide an explanation to the Veteran regarding VA's inability to obtain his or her service treatment records. Dixon v. Derwinski, 3 Vet. App. 261 (1992). The Court also has held that VA's efforts to obtain service department records shall continue until the records are obtained or unless it is reasonably certain that such records do not exist or that further efforts to obtain those records would be futile. Hayre v. West, 188 F.3d 1327 (Fed. Cir. 1999); see also McCormick v. Gober, 14 Vet. App. 39 (2000). Given the foregoing, the Board concludes that it is reasonably certain that records from Unity Health Center dated in approximately November 1984 and from the VAMC in Fayetteville, Arkansas, dated between January 1990 and December 1995 do not exist and further efforts to obtain them would be futile. As will be explained below in greater detail, the Veteran failed to report for VA examination scheduled in connection with his currently appealed claim in June 2010. Evidence which was expected from this examination could not be obtained. Neither the Veteran nor his service representative has shown good cause for his failure to report for this examination. The Court has held that "[t]he duty to assist is not always a one-way street." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Where entitlement to a benefit cannot be established or confirmed without a current VA examination and the Veteran fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. 38 C.F.R. §§ 3.655(a)-(b) (2012). After he failed to report for VA examination in June 2010, his claims file was forwarded to a VA clinician for review and an opinion concerning the contended causal relationship between the Veteran's current gastrointestinal disability and active service. The Board concludes that there is no duty to attempt to provide another examination or medical opinion. And, as VA has fulfilled the duty to notify and assist to the extent possible, the Board can consider the merits of this appeal without prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Service Connection for a Gastrointestinal Disability The Veteran contends that he incurred a gastrointestinal disability (which he characterized as GERD) during active combat service in the Republic of Vietnam. He specifically contends that he frequently sought treatment for GERD while in combat from his unit medical corpsman but this treatment was not documented in his service treatment records. He alternatively contends that his current gastrointestinal disability is related to service. Law and Regulations Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease 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). Certain chronic diseases, including peptic ulcers (gastric or duodenal), are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Establishing service connection generally requires (1) medical evidence of a presently existing 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 present disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)); Hickson v. West, 12 Vet. App. 247, 253 (1999). In the case of any Veteran who has engaged in combat with the enemy in active service during a period of war, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, condition or hardships of such service, even though there is no official record of such incurrence or aggravation. Every reasonable doubt shall be resolved in favor of the Veteran. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). Satisfactory lay or other evidence under section 1154(b) has been defined as "credible evidence." See Collette v. Brown, 82 F.3d 389, 393 (Fed. Cir. 1996). These provisions deal with the question of whether a particular disease or injury occurred in service; that is, what happened then, and not the question of either current disability or nexus to service (both of which generally require competent evidence). In other words, these provisions in 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d) do not establish presumptive service connection for a combat Veteran. Rather, they relax the evidentiary requirements for noting what happened in service. See Brock v. Brown, 10 Vet. App. 155, 162 (1997); Libertine v. Brown, 9 Vet. App. 521, 524 (1996). VA regulations provide that a Veteran who had active military, naval, or air service in the Republic of Vietnam during the Vietnam Era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. See 38 C.F.R. § 3.307(a)(6)(iii). In such circumstances, service connection may be granted on a presumptive basis for the diseases listed in 38 C.F.R. § 3.309(e). A gastrointestinal disability, to include GERD and a hiatal hernia, is not among the diseases listed in § 3.309 for which presumptive service connection is available based on in-service herbicide exposure. The Secretary of Veterans Affairs also has determined that there is no positive association between exposure to herbicides and any other condition for which he has not specifically determined a presumption of service connection is warranted. See Diseases Not Associated with Exposure to Certain Herbicide Agents, 67 Fed. Reg. 42,600 (June 24, 2002). Notwithstanding the foregoing, the Federal Circuit has determined that the Veteran's Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984) does not preclude a Veteran from establishing service connection with proof of direct causation. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The rationale employed in Combee also applies to claims based on exposure to Agent Orange. See Brock v. Brown, 10 Vet. App. 155 (1997). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). 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. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-498. In Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), the Federal Circuit recently overruled Savage and limited the applicability of the theory of continuity of symptomatology in service connection claims to those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also 38 C.F.R. § 3.309(a). With the exception of peptic ulcers (gastric or duodenal), a gastrointestinal disability, to include GERD and a hiatal hernia, is not explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a). Thus, the Board finds that Savage and the theory of continuity of symptomatology in service connection claims is inapplicable to this claim (except as discussed below). It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. Factual Background The Veteran's service treatment records show that, at his enlistment physical examination in July 1969, he denied all relevant pre-service medical history. Clinical evaluation was normal. On outpatient treatment in August 1970, the Veteran complained of a headache, vomiting, stomach pain, and diarrhea. His temperature was 100 degrees. He was prescribed Kaopectate and tetracycline for 3 days. At his separation physical examination in October 1971, clinical evaluation of the Veteran was normal. No defects or diagnoses were found. The Veteran's service personnel records show that he was in the Republic of Vietnam from May 1970 until April 1971. He participated in combat operations against the Vietcong in the Hue/Phu Bai area and while serving in Quang Nam Province, Vietnam. He was awarded the Vietnam Service Medal w/1 service star, the Combat Action Ribbon, and the Vietnam Campaign Medal w/device. He also was awarded the Navy Achievement Medal with Combat Distinguishing Device (or "V"). The citation for this award states that the Veteran served as a Team Leader and Assistant Combined Action Platoon Commander with Combined Action Platoon 2-4-5. He participated in "numerous combat patrols and ambushes [and] repeatedly distinguished himself by his courage and composure during critical situations as he aggressively maneuvered his men against enemy positions." The post-service evidence shows that, on VA outpatient treatment in August 1985, the Veteran complained of difficulty swallowing for 1 year. He reported having the same problem 1 year earlier and having "surgery to have it cleared out." The Veteran also reported a "food obstruction in mid-esophagus" approximately 6-7 months earlier although he was not sure if his esophagus had been dilated. "Now food is sticking a little." The assessment was gastroesophageal reflux and probable stricture. The Veteran was advised to take Maalox. On VA dilation of the Veteran's esophagus in September 1985, there was a small hiatal hernia, Schatzki's Ring, and no ulceration, erosions, or nodularities. The Veteran's stomach had no ulcerations, erosions, or nodularities and motility was present. The Veteran's duodenum was normal appearing with normal motility and bile present. The impressions were Schatzki's Ring and a small hiatal hernia. The Veteran was advised to take antacids as needed and to follow up in several months at the VA gastrointestinal clinic. On VA outpatient treatment in February 1992, the Veteran complained of a hiatal hernia for the previous 6-7 years treated with Maalox without relief, choking on food in the previous 5 years, and "a lot of" heartburn and acid. The Veteran stated that Zantac had worked for him. The assessment included hiatal hernia by history with esophageal reflux and rule-out esophageal stricture. The Veteran was scheduled for an upper gastrointestinal series and small bowel series. VA upper gastrointestinal series and small bowel series taken later in February 1992 was within normal limits. "Barium sulfate transits the esophagus, stomach duodenum, proximal jejunum and ileum. No difficulty and reaches the transverse colon within 40 minutes. This is fairly rapid, however, within normal limits. There is a non sliding axial hiatal hernia present with a foreshortened esophagus and at the esophagogastric junction a persistent narrowing." No varices, esophageal ulceration, or diverticuli were present. The impressions were presumed congenital short esophagus with non-sliding axial hiatal hernia and severe narrowing at the esophagogastric (EG) junction, no ulcer disease or gastroesophageal varices, a normal appearing small bowel, and early rapid transit "not unlike post operative dumping syndrome." On VA outpatient treatment in March 1992, the Veteran complained of heartburn and having problems swallowing solid foods such as steak. A history of a hiatal hernia, heartburn for 6-7 years, and dysphagia for 5-6 years worsening in the past 3-4 years was noted. The Veteran reported that he took 150 mg of Zantac twice a day for the previous 2 months. Objective examination showed an obese, non-distended, non-tender abdomen with normal bowel sounds. The assessment was hiatal hernia by upper gastrointestinal (UGI) series with possible esophageal stricture. The Veteran was advised to undergo an esophagogastroduodenoscopy (EGD). Following VA EGD in April 1992, the diagnosis was stricture of the distal esophagus due to hiatal hernia and chronic reflux esophagitis. VA barium swallow conducted in December 1992 showed an increased diameter of the gastroesophageal junction from 5 millimeters (mm) to 10 mm and a moderate degree of posterior impression and cervical portion of the esophagus which represented cricopharyngeal achalasia without evidence of aspiration of barium or reflux into the nasal pharynx. VA esophagram conducted later in December 1992 showed the same results. The Veteran had multiple esophageal dilatations by VA in the mid-1990's. For example, following esophageal dilatation in May 1994, the diagnosis was stricture of distal esophagus. VA barium swallow conducted in May 1994 showed normal deglutition in the esophagus, a prominent esophageal vestibule with a very small sliding hiatal hernia, "an area of low grade narrowing compromising the esophageal lumen by approximately 50 percent" which was "very consistent with slightly stenotic narrowing versus low grade stricture," a mild amount of gastroesophageal reflux, and esophageal motility within normal limits. The impressions were prominent esophageal vestibule with small intermittent hiatal hernia and bowel gas and esophageal reflux and an area of narrowing associated with the distal esophagus lumen with gastroesophageal junction possibly representing stenosis versus a low grade distal esophageal stricture. On private outpatient treatment in September 2000, the Veteran stated that he had not seen a doctor since 1994. A history of a hiatal hernia and questionable "nausea all the time" was noted. The assessment included hiatal hernia and gastritis. In November 2000, no relevant complaints were noted. The Veteran reported that he was "eating better [and his] stomach symptoms [were] better." He also stated that he "doesn't think he will need dilatation for achalasia." The assessment was unchanged. In May 2001, no relevant complaints were noted. The Veteran reported that he was "doing better as long as [he] takes his medicines." The assessment included hiatal hernia and gastritis. Following private outpatient treatment in February 2003, the assessment was GERD. The Veteran's wife provided the following statement in December 2007 in support of her husband's claim: [T]he hiatal hernia and reflux is a huge objection. Ever since I have known him, he has slept in a chair and chewed Rolaids. When he was young he ignored it. Until one day his food backed into his throat and choked him. He was rushed to [the] emergency [room] and had to be cleaned out under surgery. Scar tissue was so severe that his esophagus was the size of a number 2 pencil. Between village food, bad water, and nerves in Vietnam, his esophagus was ruined...That much scar tissue took time to build and I believe it is all due to eating, drinking, living, and fighting in the villages [in Vietnam]. Following a review of the Veteran's claims file, including his service treatment records and post-service VA treatment records, a VA clinician stated in October 2010 that all of the Veteran's episodes of gastroesophageal reflux disease (GERD), esophageal stricture, and esophageal reflux were documented extensively and occurred after his separation from service. He also noted the Veteran's single in-service episode in August 1970 of headache, vomiting, stomach pain, diarrhea, and an elevated temperature of 100 degrees (outlined above). This examiner found "no indication that this was gastroesophageal reflux disease. Rather, these symptoms are consistent with gastroenteritis, which is an acute viral or bacterial condition, but not typical of reflux disease." He opined that the Veteran's GERD was not as likely as not related to the in-service gastroenteritis. The Veteran asserted in a January 2011 statement that he had experienced acid reflux while on active combat service in Vietnam. "I took what medicine I could get from the Company Corpsman which would be Maalox [but] I did not know what they called it. I took it a lot for more than half my tour [in Vietnam] still I did not know the seriousness of my condition." The Veteran also asserted that he had been advised by his treating physician that his acid reflux and GERD caused his problems swallowing food. The Veteran finally asserted that his in-service unit in Vietnam never had access to fresh water and drank what water they could from the rivers and streams they encountered in combat. Analysis The Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for a gastrointestinal disability, to include GERD and a hiatal hernia, including as due to herbicide exposure. The Board notes initially that, because the Veteran, without good cause, failed to report for VA examination scheduled in June 2010, his service connection claim will be rated on the evidence of record. See 38 C.F.R. § 3.655 (2012). Because the Veteran's service personnel records show that he had in-country duty in Vietnam, his active service meets the regulatory definition of Vietnam service found in 38 C.F.R. § 3.307(a)(6)(iii) and upheld by the Federal Circuit in Haas. See Haas v. Peake, 525 F.3d. 1168 (Fed. Cir. 2008) cert. denied 129 S. Ct. 1002 (2009) (upholding as permissible VA's regulatory interpretation of "service in Vietnam" as requiring in-country duty or visitation in Vietnam). Accordingly, because the Veteran had active service in Vietnam, his in-service herbicide exposure is presumed. See 38 C.F.R. §§ 3.307, 3.309. Although the Veteran's in-service herbicide exposure is presumed, a gastrointestinal disability, to include GERD and a hiatal hernia, is not among the disabilities for which service connection is available on a presumptive basis due to in-service herbicide exposure. See 38 C.F.R. §§ 3.307, 3.309. The Veteran also has not identified or submitted any competent evidence demonstrating that his acknowledged in-service herbicide exposure caused or contributed to his current gastrointestinal disability, to include GERD and a hiatal hernia. Thus, the Board finds that service connection for a gastrointestinal disability, to include GERD and a hiatal hernia, on a presumptive basis due to in-service herbicide exposure is not warranted. Id. The Veteran also is not entitled to service connection for a gastrointestinal disability, to include GERD and a hiatal hernia, on a direct service connection basis. See 38 C.F.R. §§ 3.303, 3.304 (2012). The Veteran has contended that he incurred a gastrointestinal disability, to include GERD and a hiatal hernia, during active service or, alternatively, his current gastrointestinal disability is related to service. The record evidence does not support his assertions, however. It shows instead that, although he complained of a headache, vomiting, stomach pain, diarrhea, and an elevated temperature of 100 degrees in August 1970 while on active service, these complaints were acute, transitory, and resolved with in-service treatment (as the VA examiner concluded in October 2010). These complaints also did not result in any chronic gastrointestinal disability as the Veteran was normal clinically at his separation physical examination in October 1971. The Veteran also has contended that he frequently sought treatment from his unit medical corpsman while out in the field during his combat service in Vietnam and there were no records of this treatment. The Board notes in this regard that the lack of service treatment records demonstrating complaints of or treatment for a gastrointestinal disability does not preclude granting service connection for this disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). The Board also finds that the Veteran's report of frequent in-service treatment for unspecified gastrointestinal problems by a unit medical corpsman while out in the field seems consistent with his active combat service in Vietnam. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). As such, the Board concedes that the Veteran experienced a gastrointestinal disability during active service. The record evidence shows that, although the Veteran has complained of and been treated for a gastrointestinal disability, to include GERD and a hiatal hernia, since his service separation, it is not related to active service or any incident of service, to include his in-service treatment in August 1970 and subsequent treatment by a unit medical corpsman for a gastrointestinal disability (which was not documented in his service treatment records). Following his service separation in October 1971, it appears that the Veteran next complained of a gastrointestinal disability in August 1985, almost 14 years later, when he was diagnosed as having gastroesophageal reflux and a probable esophageal stricture. The Board notes that evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against the claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Veteran subsequently reported on outpatient treatment in September 2000 that he had not seen a doctor since 1994. The October 2010 VA examiner found "no indication" that the Veteran's August 1970 in-service treatment "was gastroesophageal reflux disease." This examiner concluded instead that the Veteran's in-service complaints of headache, vomiting, stomach pain, diarrhea, and an elevated temperature of 100 degrees in August 1970 were "consistent with gastroenteritis, which is an acute viral or bacterial condition, but not typical of reflux disease." More importantly, this examiner opined that the Veteran's gastrointestinal disability was less likely than not related to active service. The Board further finds that service connection is not warranted for a gastrointestinal disability on a presumptive service connection basis as a chronic disease. As noted elsewhere, the Veteran has contended that he incurred a chronic gastrointestinal disability (which he characterized as GERD) during service and experienced continuous gastrointestinal disability since his service separation. As also noted elsewhere, current law and regulations provide that peptic ulcers (gastric or duodenal) are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Although the Veteran does not contend that he incurred peptic ulcers during or after active service, the Board again notes that it is required to consider all theories of entitlement in service connection claims. See also Szemraj, 357 F.3d at 1371, and Roberson, 251 F.3d at 1384. The record evidence does not show that the Veteran complained of or was diagnosed as having peptic ulcers within 1 year of his service separation (i.e., by October 1972). And no ulcers were found on repeated barium swallows conducted since the Veteran's service separation. Thus, the Board finds that service connection is not warranted for peptic ulcers (gastric or duodenal) on a presumptive service connection basis as a chronic disease. See 38 C.F.R. §§ 3.307, 3.309(a). The Board finally observes that the Veteran failed to report for his VA examination in June 2010. Neither the Veteran nor his representative has provided any explanation (much less presented good cause) for his failure to report for this examination. Evidence which was expected to be obtained at this examination, including a nexus opinion concerning the contended etiological link between the Veteran's current gastrointestinal disability and active service, could not be obtained. The remaining evidence of record does not indicate that any current gastrointestinal disability, to include GERD and a hiatal hernia, is related to active service, including as due to herbicide exposure. The Veteran also has not identified or submitted any competent evidence, to include a medical nexus, which demonstrates his entitlement to service connection for a gastrointestinal disability, to include GERD and a hiatal hernia, including as due to herbicide exposure. In summary, the Board finds that service connection for a gastrointestinal disability, to include GERD and a hiatal hernia, including as due to herbicide exposure, is not warranted. In this decision, the Board has considered all lay and medical evidence as it pertains to the issue. 38 U.S.C.A. § 7104(a) ("decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) (VA "shall consider all information and lay and medical evidence of record in a case"); 38 C.F.R. § 3.303(a) (service connection claims "must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown,6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A Veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, a gastrointestinal disability, to include GERD and a hiatal hernia, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr, 21 Vet. App. at 303 ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In determining whether statements submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). As part of the current VA disability compensation claim, in recent statements, the Veteran has asserted that his symptoms of a gastrointestinal disability have been continuous since service. He asserts that he continued to experience symptoms relating to a gastrointestinal disability (GERD, difficulty swallowing food, and a hiatal hernia) after he was discharged from service. In this case, after a review of all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of a gastrointestinal disability after service separation. Further, the Board concludes that his assertion of continued symptomatology since active service, while competent, is not credible. The Board finds that the Veteran's more recently-reported history of continued symptoms of a gastrointestinal disability since active service is inconsistent with the other lay and medical evidence of record. Indeed, while he now asserts that his disorder began in service, the October 1971 service separation examination report reflects that the Veteran was examined and he was found to be normal clinically. His in-service history of symptoms at the time of service separation is more contemporaneous to service so it is of more probative value than the more recent assertions made many years after service separation. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the Veteran wrote during treatment than to his subsequent assertion years later). The post-service medical evidence does not reflect complaints or treatment related to a gastrointestinal disability for several years following active service. The Board emphasizes the multi-year gap between discharge from active service (1971) and initial reported symptoms related to a gastrointestinal disability in 1985 (a 14-year gap). See Maxson, 230 F.3d at 1333; see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where Veteran failed to account for lengthy time period between service and initial symptoms of disability). When the Veteran sought medical care with VA after service in August 1985, he did not report the onset of gastrointestinal symptomatology during or soon after service or even indicate that the symptoms were of longstanding duration. He complained instead of difficulty swallowing for 1 year (or since approximately August 1984) and a food obstruction 6-7 months earlier (or in approximately January or February 1985). In February 1992, he reported a history of a hiatal hernia for 6-7 years (or since approximately 1985-1986) and choking on food for 5 years (or since approximately 1987). One month later, in March 1992, he reported a history of dysphagia for 5-6 years and heartburn for 6-7 years. Such histories reported by the Veteran for treatment purposes are of more probative value than the more recent assertions and histories given for VA disability compensation purposes. Rucker, 10 Vet. App. at 67 (holding that lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). He did not claim that symptoms of his disorder began in (or soon after) service until he filed his current VA disability compensation claim. Such statements made for VA disability compensation purposes are of lesser probative value than his previous more contemporaneous in-service histories. See Pond v. West, 12 Vet. App. 341 (1999) (finding that, although Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). During the recent VA compensation claim, the Veteran reported the onset of symptoms to different times. Specifically, on the service connection claim he reports that his gastrointestinal symptoms began during active service. As noted above, he reported only a history of gastrointestinal symptoms since the mid-1980's when examined in February and March 1992. These inconsistencies in the record weigh against the Veteran's credibility as to the assertion of continuity of symptomatology since service. See Madden, 125 F.3d at 1481 (finding Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a Veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service). The Board has weighed the Veteran's statements as to continuity of symptomatology and finds his current recollections and statements made in connection with a claim for VA compensation benefits to be of lesser probative value than his previous more contemporaneous in-service history and findings at service separation, the absence of complaints or treatment for years after service, and his previous statements made for treatment purposes. For these reasons, the Board finds that the weight of the lay and medical evidence is against a finding of continuity of symptoms since service separation. ORDER Entitlement to service connection for a gastrointestinal disability, to include gastroesophageal reflux disease (GERD) and a hiatal hernia, including as due to herbicide exposure, is denied. ____________________________________________ G. A. WASIK Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs