Citation Nr: 1323602 Decision Date: 07/24/13 Archive Date: 08/01/13 DOCKET NO. 10-00 367A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for gastrointestinal reflux disease (GERD) (also claimed as heartburn, chronic reflux esophagitis and chronic gastritis). 2. Entitlement to service connection for a disability manifested by diarrhea and constipation. 3. Entitlement to service connection for duodenitis. 4. Entitlement to service connection for chronic inflammation in gastroesophageal junction. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran served on active duty from November 1999 to November 2003. He is in receipt of the Combat Action Ribbon, which denotes his participation in combat operations, and also had an unverified period of service in the Southwest Asia Theater of Operations. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, which denied the claims. The Board remanded the claims in October 2012 in order for the Veteran to be afforded a requested hearing. The Veteran subsequently presented testimony at a videoconference hearing before the undersigned Veterans Law Judge in January 2013. A transcript is of record. The Veteran submitted additional evidence directly to the Board in January 2013, which was accompanied by a waiver of RO consideration. The evidence will therefore be considered in this decision. 38 C.F.R. § 20.1304 (2012). The Board notes that service connection for stomach pain and loose stool was denied in an unappealed April 2004 rating decision. The Veteran's current claims are more specific and will be adjudicated de novo. See Ephraim v. Brown, 82 F.3d 399, 402 (Fed. Cir. 1996). FINDINGS OF FACT 1. The Veteran's in-service gastrointestinal complaints were less likely symptoms of his post-service current diagnoses of GERD (also claimed as heartburn, chronic reflux esophagitis and chronic gastritis), a disability manifested by diarrhea and constipation, duodenitis, and chronic inflammation in gastroesophageal junction, because they were attributable in service to a viral syndrome and are not consistent with post-service symptoms. 2. The Veteran's gastrointestinal problems have been diagnosed as GERD (as well as chronic reflux esophagitis and chronic gastritis), duodenitis, and chronic inflammation in gastroesophageal junction, which are all clinical diagnoses, and his diarrhea and constipation have been attributed to a cause other than being in the Southwest Asia Theater of Operations during the Persian Gulf War. CONCLUSIONS OF LAW 1. The criteria for service connection for GERD (also claimed as heartburn, chronic reflux esophagitis and chronic gastritis) have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2012). 2. The criteria for service connection for a disability manifested by diarrhea and constipation have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2012). 3. The criteria for service connection for duodenitis have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2012). 4. The criteria for service connection for chronic inflammation in gastroesophageal junction have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must inform the claimant about (1) the information and evidence not of record that is necessary to substantiate the claim; (2) the information and evidence that VA will seek to provide; and (3) the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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 (2006). Upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Board finds that the VCAA duty to notify was satisfied by letters sent to the Veteran in October 2006 and December 2006 with regard to the claims for service connection that are currently on appeal. The letters addressed all of the notice elements and were sent prior to the initial unfavorable decision by the agency of original jurisdiction (AOJ) in March 2007. The duty to assist was also met in this case. The service treatment records are in the claims file. All pertinent VA and private treatment records have been obtained and associated with the file. A VA examination with opinion regarding the etiology of the claimed conditions was obtained in May 2009. 38 C.F.R. § 3.159(c) (4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA opinion obtained in this case is adequate, as it is predicated on a full reading of the private and VA medical records in the Veteran's claims file. It considers all of the pertinent evidence of record and the statements of the appellant, and the examiner provided a complete rationale for the opinion stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c) (4). The Board acknowledges that the Veteran's service in the Southwest Asia Theater of Operations has not been verified. A June 2003 post deployment medical assessment indicates that the Veteran served in Kuwait and Iraq between February 2003 and June 2003. See DD Form 2844. For the purposes of adjudicating the claims currently before the Board on appeal, the Veteran's service in the Southwest Asia Theater of Operations during the reported timeframe is conceded. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent." However, 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. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). In those cases where the evidence shows that the Veteran engaged in combat with the enemy, VA will accept satisfactory lay or other evidence of service incurrence if it is consistent with the circumstances, conditions or hardship of such service, notwithstanding the fact that there is no official record of such in-service incurrence; to that end, any reasonable doubt shall be resolved in favor of the Veteran. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). In Dalton v. Nicholson, 21 Vet. App. 23, 37 (2007), the United States Court of Appeals for Veterans Claims (Court) found that while § 1154(b) relaxes the evidentiary burden for a combat Veteran with respect to evidence of an in-service occurrence of an injury, it does not create a statutory presumption that the combat Veteran's disease or injury is automatically service-connected. Rather, there must still be competent evidence of an etiological relationship between an in-service injury and a current disability. Under legislation specific to Persian Gulf War Veterans, service connection may be established for a qualifying chronic disability resulting from an undiagnosed illness that became manifest during active service in the Southwest Asia Theater of Operations during the Persian Gulf War or to a degree of 10 percent or more during a specific presumption period. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1)(i). The term "qualifying chronic disability" means a chronic disability resulting from any of the following (or any combination of any of the following): (A) an undiagnosed illness; (B) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases)) that is defined by a cluster of signs or symptoms; (C) any diagnosed illness that the Secretary determines in regulations prescribed under subsection (d) warrants presumptive service-connection. 38 U.S.C.A. § 1117(a)(2) and 38 C.F.R. § 3.317(a)(2)(i). Functional gastrointestinal disorders are a group of conditions characterized by chronic or recurrent symptoms that are unexplained by any structural, endoscopic, laboratory, or other objective signs of injury or disease and may be related to any part of the gastrointestinal tract. Specific functional gastrointestinal disorders include, but are not limited to, irritable bowel syndrome, functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, and functional dysphagia. These disorders are commonly characterized by symptoms including abdominal pain, substernal burning or pain, nausea, vomiting, altered bowel habits (including diarrhea, constipation), indigestion, bloating, postprandial fullness, and painful or difficult swallowing. 38 C.F.R. § 3.317(a)(2)(i)(B)(3), Note. Service connection for a disability due to an undiagnosed illness requires that such disability, by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. See 38 C.F.R. § 3.317(a)(1)(ii). There cannot be any affirmative evidence that relates the undiagnosed illness to a cause other than being in the Southwest Asia Theater of Operations during the Persian Gulf War. See 38 C.F.R. § 3.317(c). If signs or symptoms have been attributed to a known clinical diagnosis, service connection may not be provided under the specific provisions pertaining to Persian Gulf Veterans. VAOPGCPREC 8-98 (Aug. 3, 1998). In addition, there must be objective indications of a chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as fatigue, signs or symptoms involving the skin, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 C.F.R. § 3.317(a)(1)(b). There must be objective signs that are perceptible to an examining physician and other non-medical indicators that are capable of independent verification. There must be a minimum of a six-month period of chronicity. 38 C.F.R. § 3.317(a)(2)(3). Compensation shall not be paid, however, if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval or air service in the Southwest Asia Theater of Operations during the Persian Gulf war; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or events that occurred between the appellant's most recent departure from active duty in the Southwest Theater of Operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the appellant's own willful misconduct or the abuse of alcohol or drugs. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(c). As noted above, the Board is conceding that the Veteran served in the Southwest Asia Theater of Operations for the purpose of adjudicating the claims on appeal. Therefore, he qualifies for consideration for presumptive service connection for disabilities resulting from undiagnosed illness or unexplained chronic multi-symptom illness. 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. The Veteran seeks service connection for GERD (also claimed as heartburn, chronic reflux esophagitis and chronic gastritis); duodenitis; chronic inflammation in gastroesophageal junction; and a disability manifested by diarrhea and constipation. His basic assertion is that these gastrointestinal problems began during his deployment in the Southwest Asia Theater of Operations as a result of the food he consumed there, and that his problems have continued since then. The Veteran contends that he was seen in service for gastrointestinal symptoms and complaints but was only given medication, which only provided temporary relief, and was not subjected to any diagnostic testing to determine the source of his complaints. See e.g., VA Forms 21-4138 dated January 2004 and July 2006; July 2006 VA Form 21-526; undated statement in support of claim; January 2013 transcript. Several lay statements have been submitted in support of the Veteran's claim. J.G. reports that he has known the Veteran since boot camp, during which time they ate the same food and did most things together, to include going to the gym. J.G. reports that after his deployment to Iraq, the Veteran's health declined and that they stopped eating and going to the gym together due to his illness and the fact that he could not eat regular food anymore. J.G. asserts that the Veteran's sickness is due to his deployment. See undated statement. The Veteran's sister reports that they were together until the Veteran joined the military and that he was healthy and hearty before his deployment to Iraq but that when he returned, he had health problems and had been on over-the-counter and prescribed medications since then. See November 2006 statement from E.I. In a December 2006 statement, H.C.I. reports that he has known the Veteran since his birth and lived with him before service. H.C.I. asserts that the Veteran did not have any problems prior to service and developed these problems after his return from Iraq. The Veteran's service treatment records reveal that he was seen in July 2002 with complaint of upset stomach. He reported having four bowel movements that morning and that his stool consistency was watery but of normal color and without blood. The Veteran indicated that he had not eaten any food that would normally upset his stomach and that he had a similar problem, though milder, about six months prior, which went away on its own that same day. During examination of the Veteran's abdomen, there was objective evidence of normoactive bowel sounds (NABS) and the abdomen was noted to be soft and nontender without rebound tenderness. The assessment was diarrhea. The Veteran was given Imodium and put on light duty for five days with instructions for follow up. There is no indication that he was seen for follow up. A June 2003 post deployment medical assessment indicates that the Veteran denied persistent diarrhea or constipation and recent unexplained gain or loss of weight. See DD Form 2844. The Veteran was seen in September 2003, at which time examination of his abdomen revealed minor distention, possibly secondary to gas, but no rigidity or palpable masses. Bowel sounds were normal and there was no tenderness to palpation or rebound tenderness. The assessment was viral syndrome. The Veteran was returned to full duty and told to take medications for fever, pain and congestion. The Veteran did not note any gastrointestinal complaints at the time of a September 2003 report of medical assessment (completed prior to the treatment he received that same month for a viral syndrome) and when assessed for separation in October 2003, the health care provider also did not note any gastrointestinal complaints. See DD Form 2697; see also October 2003 health record entitled Separation Physical Examination. The post-service medical evidence of record includes an October 2003 VA general medical examination, which was conducted in conjunction with the Veteran's original claim for service connection filed in October 2003, prior to his discharge from active duty service. The Board notes that the Veteran did not include any gastrointestinal complaints in his original claim. During the October 2003 VA general medical examination, physical examination of the Veteran's systems revealed that stomach and bowel functions were normal. Examination specific to his abdomen revealed that it was negative without herniae, enlarged organs, or abdominal masses detected. Private treatment records include a typewritten report from the General Mutual Hospital in Nigeria (where the Veteran testified he was on vacation following his discharge from service). This report reveals that the Veteran was admitted on December 20, 2003, with complaint of upset stomach, being unable to swallow, heartburn, soreness in the lower and upper abdomen, having reflux and bloating after a meal, and sleep deprivation. The Veteran reported that he had been having these problems since he came back from his deployment. After medical evaluation, treatment was provided and prescription was given with a special diet recommendation. The Veteran was discharged two days later for further medical treatment at his request. No diagnosis was provided and the prescribed treatment was not specified. Records associated with this treatment are largely illegible. In July 2004, the Veteran was seen at the Medic Clinic at Hillcroft with complaint of occasional stomach pain with eating three to four times a week. The Veteran denied vomiting but did report nausea and sometimes feeling bloated. He also indicated decreased appetite but denied weight loss. Pain was usually located about the right mid quadrant and the Veteran reported occasional constipation. He indicated taking Pepto Bismol, which turned his stools black. Physical examination of the abdomen was reportedly abnormal. The abdomen was soft and tender in the right upper quadrant area but there was no guarding or rebound and bowel sounds were present. The assessment was abdominal pain, not otherwise specified (NOS). It was noted that x-ray looked ok and that the Veteran would need an ultrasound if systems persist. Pepcid was prescribed. The July 2004 x-ray associated with this visit reveal that gas pattern did not suggest acute abnormality and there was no mass or suspicious calcification seen and no impaction noted. The impression was no acute abnormality noted. The Veteran underwent an upper GI endoscopy with biopsy in July 2006. The endoscopy was performed for the evaluation of dysphagia. The findings included inflammation in the gastroesophageal junction. The endoscopic impression was inflammation in the gastroesophageal junction and normal stomach, antrum, duodenal bulb, duodenal folds, and ampullary area. Biopsy of the duodenum revealed a mild increase in chronic inflammatory cells in the lamina propria and mild Brunner gland hyperplasia, features suggestive of peptic duodenitis. Biopsy of the stomach revealed mild changes consistent with reactive gastropathy with mild chronic inflammation. Biopsy of the gastroesophageal junction revealed squamous mucosa with no significant histopathologic change. There was no evidence of helicobacter pylori organisms, dysplasia, or malignancy. See records from Physicians Endoscopy Center and AmeriPath GI Institute. In a statement received in November 2006, Dr. R.L.A. reported that the Veteran had documented chronic reflux esophagitis, chronic gastritis and duodenitis, and that he has required continuous PPI therapy with esomeprazole (Nexium). Dr. A. attached the July 2006 records discussed in the preceding paragraph. In an August 2010 record from this same provider, the Veteran was seen with complaint of inflammation of his stomach, gas in his stomach, and left-sided pain. It was noted he was on Nexium and Gaviscon chewable. No findings specific to the abdomen were noted on examination. The impression was history of GERD/gastritis. Nexium was prescribed and the Veteran was advised to return in a year. The Veteran underwent an upper GI endoscopy in February 2011 due to epigastric abdominal pain and abdominal pain in the right upper quadrant. Findings included localized mild inflammation characterized by congestion (edema) in the gastric antrum but no gross lesions in the entire esophagus. The impression was no gross lesions in esophagus; gastritis; and no gross lesions in duodenum. See records from Endoscopy Center of Lodi, L.L.C. VA treatment records from the facility in Houston, Texas, do not include any complaints of, or treatment for, gastrointestinal problems. The Veteran has submitted two private medical opinions in support of his claim. In a July 2007 document, Dr. H.G.B. reported to the Veteran that he had reviewed the claims folder, to include service treatment records, medical records since discharge, communication with VA, physicians' letters, letters from friends, and laboratory reports and x-rays, to form an opinion as to whether the health problems that started in service while deployed in Iraq are related to his present problems. It was Dr. B's opinion that it is as likely as not the Veteran developed GERD, gastritis and duodenitis while deployed in Iraq. Dr. B. explained that this triad continued and was treated within the first year after discharge, and continued to be symptomatic at present. Dr. B. reported that the opinion was based on review of the service and private treatment records, the relevant medical literature, and Dr. B's thirty years of experience as a Board certified general, vascular and trauma surgeon with extensive professional experience in the medical and surgical treatment of gastrointestinal diseases. A resume was attached. Dr. B. included a medical history, in which it was reported that the Veteran enlisted in November 1999 and was in good health without history of gastrointestinal complaints. He was deployed to Iraq and soon developed symptoms of upper abdominal pain, heartburn, difficulty swallowing, occasional diarrhea, and the inability to eat. Dr. B. reported that the Veteran was in Iraq between March 2000 and November 2000 and that he was seen in July 2002 with upper abdominal pain, upset stomach and diarrhea. He reported similar problems about six months before but that it had gone away without specific treatment. There was no diagnosis indicated on the chart and he was treated with Imodium. Dr. B. reported that the Veteran continued to have intermittent symptoms by history that changed his habits. In a letter from J.G., it was reported that the Veteran had a bad stomach from eating "bad food." Mr. G. went on to say that he could not eat normally and could not go to the gym as he once had. The Veteran was seen again in September 2003 with a tender abdomen and "loose stools" but this was ascribed to a viral syndrome without much evaluation. Dr. B. noted that the Veteran's gastrointestinal problems were never thoroughly evaluated while on active duty and he was discharged in November 2003. Dr. B. reported that the Veteran was seen in July 2004 at Hillcroft Medical Clinic for upper abdominal pain with upset stomach and nausea three to four times a week. He also complained of a burning pain in the chest and took Pepto Bismol and Tums with temporary relief. X-rays (flat and upright of abdomen) were normal as were his laboratory studies. No diagnosis was entered on the chart. He was started on Pepcid and told to return if symptoms persisted. He got some relief from the Pepcid but he continued to have intermittent symptoms of upper abdominal pain, heartburn, and upset stomach. Finally, after suffering from these symptoms much of the time, he consulted a gastroenterologist, Dr. R.A., who did an esophageal, gastro, duodenal fiber optic endoscopy with multiple biopsies that showed chronic GERD, chronic gastritis, and chronic duodenitis. He was treated with Esomeprazol, a proton pump inhibitor. In an October 2006 letter, Dr. A. confirmed the diagnoses of chronic GERD, chronic gastritis, and chronic duodenitis. In December, he spent three days in a hospital in Nigeria with the same complaints of "heartburn, abdominal pain, difficult swallowing, reflux and bloating." By history he continues having these same symptoms intermittently to the present. He states the pain makes it hard for him to work. Dr. B. included a discussion, in which it was noted that idiopathic duodenitis and gastritis make up 30 percent of patients diagnosed with duodenitis and gastritis. The most common cause is aspirin or nonsteriodal anti-inflammatory drugs (NSAIDS). Stress and alcohol are also implicated. Dr. B. cited to medical literature relied upon in providing that information. Dr. B. also cited to medical literature in stating that Helicobacter pylori is an important cause of peptic ulcer disease, but it does not seem to play a role in gastritis, duodenitis and GERD. Dr. B. reported that the Veteran was negative for H-pylori and also had no history of using alcohol or NSAIDS. It was noted that the Veteran had not been tested for Zollinger-Ellison Syndrome (ZES), but these gastrin producing gastrinomas are rare. Dr. B. noted that the Veteran is being treated with proton pump inhibitor (Nexium), which is the treatment choice for ZES, but they are also used to treat idiopathic gastritis, duodenitis, and GERD, which is the Veteran's type. This type is associated with the same symptoms that he has and they are upper abdominal pain, heartburn, pain in the chest and throat that makes it seem hard to swallow, and bloating. These are the same symptoms that the Veteran had on multiple clinic visits while in service. A more aggressive approach by military doctors might have resulted in his being appropriately treated much sooner. Dr. B. concluded by saying in summary that it was his opinion that as likely as not, the Veteran developed idiopathic GERD, chronic gastritis, and chronic duodenitis, while deployed in Iraq. He was seen multiple times for symptoms consistent with this disease complex. He continues to have this diagnosis proven by multiple biopsies. The Board notes at this juncture that Dr. B. referenced that the Veteran was in Iraq between March 2000 and November 2000. It appears that this statement was made in reference to a post-deployment health assessment dated in December 2000, which references Europe and Africa, not Southwest Asia, as the location of the Veteran's operation. The Board also notes that the chronology of the Veteran's care as reported by Dr. B. is incorrect, as the Veteran was seen in Nigeria in December 2003, not in December following the October 2006 letter from Dr. A. that confirmed the diagnoses of chronic GERD, chronic gastritis, and chronic duodenitis. The Board does not find that either discrepancy is of consequence. The Veteran testified in January 2013 that he had not seen Dr. B. since he wrote the July 2007 document. In a September 2007 document, Dr. C.N.B. reported that he had reviewed the Veteran's medical records for the purpose of making a medical opinion concerning his GI disease as it relates to his service time and that in order to make an evaluation, he had carefully considered service treatment records, post-service medical records, imaging reports, the Veteran's 2007 lay statement, the rating decision, other medical opinions, and medical literature. Dr. B. reported that he had special knowledge in the area of GI disease due to his certifications, provided a resume, and discussed his competency to provide an opinion. Dr. B. reported the following facts: that the Veteran entered service fit for duty; that the Veteran had several visits to medical personnel during service for GI problems and shortly after service in 2004; that the Veteran was admitted for heartburn in Nigeria in December 2003; that the Veteran has submitted buddy statements that document upper GI problems during service; and that the Veteran has had several upper endoscopies for dyspepsia and has diagnosed GERD, chronic gastritis, and duodenitis as per Dr. A. Dr. B. reported that it is clear this Veteran currently has significant serious GI disease in the form of GERD, gastroesophageal junction inflammation, inflammation of the lamia propria, Brunner gland hyperplasia, duodenitis, diarrhea, and constipation. This Veteran had upper GI complaints in service according to the buddy statements and Dr. B's clinical interview. The Veteran's in-service complaints are likely the first signs and symptoms of his now well-documented upper GI problems in the form of GERD, gastroesophageal junction inflammation, inflammation of the lamia propria, Brunner gland hyperplasia, duodenitis, diarrhea, and constipation for the following reasons: (1) he entered fit for duty; (2) he developed upper GI problems in service; (3) he had hospitalization of upper GI problems very shortly after service in 2003; (4) his record documents that his upper endoscopies show multiple upper GI problems, all of which are consistent with his service time GI signs and symptoms; (5) his record does not contain a more likely etiology for his current signs and symptoms; (6) his acute (post-service) and chronic (service time) signs, symptoms and lay/buddy statements are all consistent with diagnosis of chronic upper GI inflammatory disease; and (7) his file does not contain a medical opinion to the contrary. The Veteran testified in January 2013 that he had no treatment records from Dr. B. The Veteran was afforded VA esophagus and hiatal hernia and stomach, duodenum and peritoneal adhesions examinations in May 2009, at which time his claims folder and medical records were reviewed. The examiner noted that a December 2000 post-deployment questionnaire was negative for referral of GI complaints. It appears that the VA examiner relied upon the same December 2000 post-deployment health assessment that Dr. B. referenced in July 2007, which was related to the Veterans' deployment in Europe and Africa, not Southwest Asia. The examiner also noted the July 2002 in-service complaint of upset stomach, the June 2003 post-deployment medical assessment, which did not note any specific deployment concerns, and the October 2003 separation examination, in which no complaints or diagnosed disability related to the claimed issues/symptoms, were noted. The examiner also reported reviewing private medical records, to include the opinions received from both Dr. B's, the statement and test results submitted by Dr. A., and the record from General Mutual Hospital. Lastly, the examiner reported reviewing the lay statements and statements made by the Veteran. In pertinent part, it was noted that the Veteran had service between 1999 and 2003, that he was taking current medication in the form of Nexium, Gaviscon, and Zantac (for heartburn), and that he had a pertinent past medical history of GERD, chronic esophagitis, chronic gastritis, and chronic duodenitis. The Veteran reported that GERD, chronic esophagitis, chronic duodenitis, and chronic gastritis all onset in 2003 and that he first had symptoms of burning pain in his chest, nausea and pain after eating in 2003, after his return from Iraq. He indicated that he sought medical care and was given antacid once or twice. He indicated that he went back for treatment several times and had no relief from the antacid, but was given no other medication. He was never evaluated by esophagogastroduodenoscopy (EGD) or upper gastrointestinal series (UGI). The examiner reported that service treatment records indicate that the Veteran was seen twice for GI related complaints. He was seen in July 2002 for upset stomach and symptoms included four loose bowel movements, which were watery and without blood, but no abdominal pain or vomiting were reported. He indicated he had had a similar episode six months before and was diagnosed with diarrhea. He was issued Imodium and advised to return for follow up within a few days if symptoms did not improve. The examiner noted there was no evidence that the Veteran returned for follow up and that there is no mention of heartburn, nausea/vomiting, or upper gastrointestinal symptoms in the progress note. The next note of GI problem is in September 2003. At that time, the Veteran reported multiple symptoms, including fever at night, headache for two days, malaise, night sweats, chills, and mild loose stools. Per progress note, the Veteran reported no prior history of symptoms and had slight nasal congestion. On exam he was noted to have minor abdominal distention with normal bowel sounds throughout. Assessment was viral syndrome. Veteran was returned to full duty. There is no mention of heartburn, nausea/vomiting, or upper gastrointestinal symptoms in the progress note. The examiner reported that the October 2003 separation physical does not document any gastrointestinal complaint and that the post deployment health assessment also did not identify any exposure concerns. The examiner reported that after military service, the Veteran reported having severe abdominal pain and heartburn in December 2003 when he was hospitalized in Nigeria and evaluated for his symptoms. The Veteran reported that the treatment given there did not help him. The Veteran reported he was next seen by Mediclinic in July 2004. The examiner noted that the progress note from this visit indicates the diagnosis was abdominal pain, NOS, and symptoms included stomach pain times eight months, heartburn, burning chest pain, and occasional constipation with the Veteran taking Pepto Bismol and Tums prior to the visit. He was given a prescription for Pepcid which the Veteran reported had "slowed down" his symptoms for a while. The Veteran went to Memorial Southwest Hospital in 2006 and had an EGD done by Dr. A to evaluate problems with dysphagia. Per review of the notes, the EGD found normal stomach, duodenal bulb, and inflammation of the gastroesophageal junction. An October 2006 letter from Dr. A. stated that pathology from EGD biopsy revealed chronic reflux esophagitis, chronic gastritis, and duodenitis. The examiner reported that the Veteran had provided a lay statement from J.G., who reported that he thought the Veteran's sickness was due to deployment to Iraq, and statements from paid consultants, Dr. B. in a July 2007 letter and Dr. B. in a September 2007 letter, with opinions based on record review. The examiner noted that it was the opinion of both that the Veteran's symptoms began in service and are related to military service. The examiner noted, however, that no symptoms of nausea/vomiting, heartburn, indigestion, epigastric pain, dysphagia, odynophagia, regurgitation, or other symptoms referable to upper gastrointestinal tract are noted in the service treatment records. The Veteran reported the onset of diarrhea and constipation in 2002. The examiner noted that the Veteran had two separate episodes of acute diarrheal illness, one treated in July 2002 and one in September 2003. There is no indication that the Veteran had any symptoms in the interim and he did not report any gastrointestinal symptoms on his post-deployment health assessment or his separation physical. It was noted that the Veteran reported constipation as occurring intermittently when he was seen in July 2004 by Mediclinic for complaint of abdominal pain and that he was taking both Pepto Bismol and Tums at that time. The Veteran reported that occasional diarrhea and constipation still occur, but was noted by the examiner to be vague regarding frequency. He indicated that nausea and vomiting occurred around two times per week and reported dysphagia, but not odynophagia. Abdominal pain at least a few times per week was reported by the Veteran, as were problems with gaseous distention and heartburn, relieved by Gaviscon. The Veteran also reported regurgitation of food and liquid occurred around once per week and belching several times a day. He noted early satiety and a 30 pound weight loss in the past two years. The examiner noted that the Veteran's current weight was 160 pounds and that he was 168 pounds in the 2003 General Mutual Hospital summary. It was also noted that the Veteran denied hematemesis, hematochezia and melena. Following physical examination and diagnostic testing in the form of laboratory tests, diagnoses of chronic esophagitis, GERD, chronic gastritis, chronic duodenitis, and diarrhea and constipation were made. It was the examiner's opinion that it is less likely than not that the Veteran's chronic esophagitis, GERD, chronic gastritis and chronic duodenitis are related to military service. The rationale employed included a finding that from review of the claims folder and private records provided by the Veteran, chronic esophagitis, GERD, chronic gastritis, and chronic duodenitis were diagnosed by EGD in 2006. The examiner included a finding that there was no evidence that the Veteran was seen for symptoms consistent with chronic esophagitis, GERD, chronic gastritis, or chronic duodenitis while he was on active duty military status. It was noted that he was only seen twice for diarrhea while in service and did not report symptoms of heartburn or indigestion on those occasions. It was also noted that in the July 2004 Mediclinic progress note, the Veteran stated he had symptoms for nine months, which would put onset around November 2003. The examiner pointed out that the opinion provided by Dr. B. in July 2007 did not accurately reflect the Veteran's medical history in terms of chronological order and symptom presentation described in the military is not the same as reflected in the service treatment records. The examiner also pointed out that in the opinion provided by Dr. B. in September 2007, the September 2003 progress note reviewed did not contain an assessment and plan. The examiner was of the opinion that if these facts were changed there was no basis for the opinion that the Veteran's chronic esophagitis, GERD, chronic gastritis, and chronic duodenitis were service related. As for the diagnosed diarrhea and constipation, the examiner reported that although acute diarrheal illnesses were documented in service, there was no evidence of a chronic condition. In addition, the Veteran was reporting intermittent diarrhea and constipation since discharge from service, but was vague regarding frequency and symptoms. It was the examiner's opinion that it would be mere speculation to state that the Veteran's military service is the cause of his diarrhea and constipation. The rationale employed was that the Veteran noted intermittent constipation in 2004 and was frequently taking Pepto Bismol and Tums at that time, both of which commonly cause constipation. The examiner also noted that at the current time, the Veteran was taking Nexium, Gaviscon and Zantac, all of which have diarrhea and constipation as a possible side effect and can also cause abdominal pain and nausea. The preponderance of the evidence is against the claim for service connection for GERD (also claimed as heartburn, chronic reflux esophagitis and chronic gastritis), a disability manifested by diarrhea and constipation, duodenitis, and chronic inflammation in gastroesophageal junction, on a direct basis. The Board acknowledges the in-service gastrointestinal problems, complaints and assessments, and the diagnoses of inflammation in the gastroesophageal junction, chronic esophagitis, GERD, chronic gastritis, chronic duodenitis, and diarrhea and constipation made during the course of the Veteran's appeal. Given the in-service and post-service evidence, the Board finds that the Veteran has two of the three elements needed to establish service connection, namely evidence of in-service incurrence of gastrointestinal problems and evidence of a current disability. Therefore, the question that remains to be resolved in this case is whether there is an etiological relationship between the in-service complaints, problems and assessments and the post-service or current complaints, problems and diagnoses. There are three medical opinions of record that address this question. Prior to discussing the opinions, however, the Board must acknowledge the lay statements that have been submitted in support of the Veteran's claim. As noted above, J.G. reported that the Veteran stopped eating and could not eat regular food after his deployment to Iraq. J.G. is competent to report this symptomatology and the Board finds these contentions to be credible. J.G.'s assertion that the Veteran's sickness, which is not specified, is due to his deployment is not competent as there is no indication that J.G. is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See 38 C.F.R. § 3.159(a)(1). As such, this opinion is not afforded any probative value. Also as noted above, E.I. and H.C.I. both reported that they had known the Veteran before service, that the Veteran had had no problems prior to service, and that his problems began after his service in Iraq. Neither individual specifically indicated what health problems the Veteran had after his service, nor has either described any associated symptomatology. Therefore, these lay statements are not afforded any probative value. The private opinion provided by Dr. B. in July 2007 was succinctly stated that it is as likely as not that the Veteran developed GERD, gastritis and duodenitis while deployed in Iraq and that this triad continued and was treated within the first year of discharge and continued to be symptomatic at present. The opinion was supported by a detailed rationale with specific discussion of the in-service and post-service medical evidence, as well as the symptomatology reported by the Veteran since discharge. Although a detailed rationale was provided, the Board finds that the opinion provided by Dr. B. in July 2007 is based on an inaccurate factual premise, namely the finding that the post-service symptoms of upper abdominal pain, heartburn, pain in the chest and throat that made it seem hard to swallow, and bloating, are the same symptoms that the Veteran had on multiple in-service clinic visits. Service treatment records only document symptoms of upset stomach, multiple bowel movements one morning, and watery stool, with resulting assessment of diarrhea, and minor abdominal distention, possibly secondary to gas, with assessment of viral syndrome. There are no documented complaints of heartburn or pain in the chest and throat that made it seem hard to swallow during service. As the opinion is based on an inaccurate factual premise, it is not afforded any probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative); see also Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely") (citing Reonal)). The private opinion provided by Dr. B. in September 2007 that the Veteran's in-service complaints are likely the first signs and symptoms of his now well-documented upper GI problems in the form of GERD, gastroesophageal junction inflammation, duodenitis, and diarrhea and constipation, was also supported by a rationale, but is also not afforded any probative value. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (a factor for assessing the probative value of a medical opinion includes the thoroughness and detail of the opinion). This is so because Dr. B. does not provide an adequate explanation as to the finding that upper endoscopies show multiple upper GI problems that are consistent with the Veteran's service time GI signs and symptoms. More specifically, Dr. B. does not detail what upper GI problems on post-service endoscopy and in-service GI symptomatology are consistent with each other. Moreover, and as discussed in the preceding paragraph, the in-service and post-service symptomatology are not identical. This leaves the opinion provided by the May 2009 VA examiner, which accurately reported in-service gastrointestinal symptomatology and made a specific finding that none of the symptoms referable to the upper gastrointestinal tract (such as nausea/vomiting, heartburn, indigestion, epigastric pain, dysphagia, odynophagia, and regurgitation) were noted during service. The May 2009 VA examiner also accurately reported the post-service gastrointestinal symptomatology and acknowledged the lay statement provided by J.G. before determining that it was not until 2006 that the Veteran was diagnosed with chronic esophagitis, GERD, chronic gastritis and chronic duodenitis and that the Veteran was not seen for symptoms consistent with these diagnoses while in service. The examiner also determined that the Veteran did not have a chronic diarrhea condition during service and that the Veteran has only reported intermittent diarrhea and constipation since service. The examiner explained that it would be speculative to link the Veteran's diarrhea and constipation to service since diarrhea was acute, not chronic, during service, and since the Veteran has only reported intermittent, not chronic, diarrhea and constipation since service. The examiner further explained that diarrhea and constipation are common side effects of many of the medications the Veteran has taken since discharge from service, to include Pepto Bismol, Tums, Nexium, Gaviscon and Zantac. This opinion is afforded high probative value due to the detailed and accurate rationale provided in support of it. Id. The only probative opinion of record establishes that there is no etiological relationship between the Veteran's in-service gastrointestinal complaints and his current diagnoses of GERD (also claimed as heartburn, chronic reflux esophagitis and chronic gastritis), a disability manifested by diarrhea and constipation, duodenitis, and chronic inflammation in gastroesophageal junction. In the absence of probative evidence establishing such an etiological relationship, service connection on a direct basis for GERD (also claimed as heartburn, chronic reflux esophagitis and chronic gastritis), a disability manifested by diarrhea and constipation, duodenitis, and chronic inflammation in gastroesophageal junction must be denied. 38 C.F.R. § 3.303. Service connection is also not warranted on a presumptive basis. The Veteran's gastrointestinal problems have been associated with and diagnosed as GERD (as well as chronic reflux esophagitis and chronic gastritis), duodenitis, and chronic inflammation in gastroesophageal junction, which are all clinical diagnoses. His diarrhea and constipation have been attributed to a cause other than being in the Southwest Asia Theater of Operations during the Persian Gulf War, namely the medications he has taken, to include Pepto Bismol, Tums, Nexium, Gaviscon and Zantac. In addition, the VA examiner indicated that there is no evidence of chronic diarrhea during service, but rather acute diarrhea, and also no evidence of chronic constipation since service as the Veteran has only reported intermittent constipation. The finding of intermittent diarrhea and constipation, based on the Veteran's history, was also noted by Dr. B. in July 2007. Moreover, the Veteran did not note any gastrointestinal complaints at the time of his separation from service. See September 2003 report of medical assessment and October 2003 Separation Physical Examination. These histories, made more contemporaneous to service, have greater probative value than the history more recently reported by the Veteran that his problems have continued since his deployment to the Southwest Asia Theater of Operations. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest in the outcome of a proceeding may affect the credibility of testimony). For these reasons, service connection on a presumptive basis for GERD (also claimed as heartburn, chronic reflux esophagitis and chronic gastritis), a disability manifested by diarrhea and constipation, duodenitis, and chronic inflammation in gastroesophageal junction must be denied. 38 C.F.R. § 3.317. ORDER Service connection for gastrointestinal reflux disease (GERD) (also claimed as heartburn, chronic reflux esophagitis and chronic gastritis) is denied. Service connection for a disability manifested by diarrhea and constipation is denied. Service connection for duodenitis is denied. Service connection for chronic inflammation in gastroesophageal junction is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs