Citation Nr: 1323629 Decision Date: 07/24/13 Archive Date: 08/01/13 DOCKET NO. 04-02 913 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for an upper gastrointestinal disorder, to include as secondary to a service-connected disability. 2. Entitlement to service connection for hypertension, to include as secondary to a service-connected disability. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD A. D. Jackson, Counsel INTRODUCTION The Veteran served on active duty from February 1974 to July 1979. This matter comes on appeal before the Board of Veterans' Appeals (Board) from a March 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office in New Orleans, Louisiana (RO). The Veteran testified at an August 2005 Travel Board hearing; the hearing transcript has been associated with the claims file. The Board remanded the case to the RO for further development in June 2006, March 2010, and March 2012. The case has since returned to the Board for further appellate consideration. In May 2013, the Veteran submitted an additional statement to the Appeals Management Center (AMC) in Washington, DC, with a waiver of initial RO consideration. See Representative's June 2013 memorandum. FINDINGS OF FACT 1. The most probative (competent and credible) medical and other evidence of record shows that the Veteran's hiatal hernia is a congenital defect that preexisted the Veteran's period of active service, and was not permanently made worse therein by way of superimposed disease or injury in service; and is unrelated to his service-connected residuals of an appendectomy and small bowel obstruction. 2. The most probative (competent and credible) medical and other evidence of record indicates that a upper gastrointestinal disorder to include GERD is less likely than not related to his military service, including his service-connected residuals of an appendectomy and small bowel obstruction. 3. The most probative (competent and credible) medical and other evidence of record indicates the Veteran's hypertension is less likely than not related to his military service, including his service-connected residuals of an appendectomy and small bowel obstruction. CONCLUSIONS OF LAW 1. An upper gastrointestinal disorder, to include hiatal hernia and GERD, was not incurred in or aggravated by active service, and is not proximately due to, the result of, or aggravated by service-connected residuals of an appendectomy and small bowel obstruction. 38 U.S.C.A. §§ 1110, 1111, 1131, 1153 (West 2002); 38 C.F.R. §§ 3.304, 3.306, 3.310, 4.57 (2012); Allen v. Brown, 7 Vet. App. 439 (1995). 2. Hypertension was not incurred in or aggravated by his military service, may not be presumed to have been incurred in or aggravated by service, and is not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Duties to Notify and Assist VA has duties to notify and assist the Veteran in substantiating this claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Proper notice must inform him of the information and medical or lay evidence not of record: (1) that is necessary to substantiate this claim; (2) that VA will obtain and assist him in obtaining; and (3) that he is expected to provide. See 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). The Veterans Claims Assistance Act (VCAA) notice requirements apply to all five elements of this service-connection claim: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and this disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Further, this notice must include information that a "downstream" disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. The Veteran was provided this required notice in letters dated in February 2001, May 2001, and July 2006. The February and, May 2001 letters informed him of the evidence required to substantiate this claim and of his and VA's respective responsibilities in obtaining this supporting evidence. The July 2006 letter complied with Dingess by as well discussing the "downstream" disability rating and effective date elements of his claim. These 2001 notice letters were sent to the Veteran prior to the adjudication of the claim in March 2002. Thereafter, an additional VCAA notice letter was sent to him in July 2006 following the Board remand. Subsequently, after receiving all VCAA notice, his claim was readjudicated by way of a February 2009 supplemental statement of the case. VCAA notice errors, including in timing and content, are not presumptively prejudicial - rather, must be determined on a case-by-case basis. And as the pleading party attacking the agency's decision, the Veteran, not VA, has this burden of proof of showing there is a VCAA notice error in timing or content but, above and beyond this, that it is unduly prejudicial, meaning outcome determinative of his claim. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). So absent this pleading or showing in this instance, the duty to notify has been satisfied. And as for the duty to assist, the RO and AMC obtained the Veteran's service treatment records (STRs), as well as his post-service VA and private treatment records. While the Veteran has reported treatment by a physician that treated him immediately after service, he has indicated that these records are unavailable due to the death of the physician. With respect to his hearing before the undersigned, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans law Judge (VLJ) who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, while the undersigned did not specifically note the bases of the prior determinations or the elements that were lacking to substantiate the Veteran's appellate claims, the Board notes that the testimony of the Veteran, to include the questions posed by his accredited representative, focused on the elements necessary to substantiate the appellate claim i.e., the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. Further, during the hearing, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. Finally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor has he identified any prejudice in the conduct of this hearing. As such, the Board finds that, consistent with Bryant, the duties set forth in 38 C.F.R. 3.103(c)(2) have been satisfied. The Board also remanded these claims to obtain additional VA medical nexus opinion concerning the determinative issue of the etiology of his claimed conditions - and specifically insofar as the likelihood they are related or attributable to his military service including by way of secondary service connection. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). See also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The VA compensation examiner designated to provide the medical nexus opinions has responded with her findings, and the opinion is responsive to this determinative issue of causation, so, there was compliance with the remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Chest v. Peake, 283 Fed. App. 814 (Fed. Cir. 2008); and Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Thus, the duty to assist the Veteran with these claims also has been satisfied. II. General Statutes, Regulations and Precedent Cases Governing Claims for Service Connection The Veteran reports that he was treated for variously diagnosed gastrointestinal problems during his military service. Specifically, he underwent an appendectomy and surgical removal of a bowel obstruction, and since then he has had abdominal problems to include a hiatal hernia and GERD. As such, he believes that these conditions had their onset during service and developed as a result of his in-service surgery. In the alternative, he claims that his hiatal hernia and GERD are aggravated by his service-connected residuals of an appendectomy and small bowel obstruction; therefore, service connection should be granted on a secondary basis. In general, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Thus, to establish entitlement to direct service connection for the claimed disability, there must be: (1) competent and credible evidence confirming the Veteran has the claimed disability - or, at the very least, showing he has at some point since the filing of his claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or injury; and (3) competent and credible evidence of a nexus or link between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002). The second and third elements may be established by showing continuity of symptomatology for chronic diseases specifically listed at 38 C.F.R. § 3.309(a) such as hypertension. 38 C.F.R. § 3.303(b) see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Continuity of symptomatology may be shown by demonstrating: "(1) that a condition was 'noted' during service or any applicable presumption period; (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." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). Service connection may be presumed for certain chronic diseases, such as hypertension, which are manifest to a compensable degree within the year after qualifying active service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) and (b). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Medical evidence also is generally required to associate the claimed condition with a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Velez v. West, 11 Vet. App. 148, 158 (1998); and McQueen v. West, 13 Vet. App. 237 (1999). A veteran is presumed to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. §§ 1111, 1132; 38 C.F.R. § 3.304(b). History provided by a Veteran of the pre-service existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a preexisting condition. 38 C.F.R. §§ 3.304(b)(1); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1995). To rebut the presumption of sound condition for disorders not noted on the entrance examination report, VA must show by clear and unmistakable evidence that the disability existed prior to service and was not aggravated by service. 38 U.S.C.A. § 1111; VAOPGCPREC 3- 2003. The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. Service connection may not be granted for congenital or developmental defects. 38 C.F.R. §§ 3.303(c) and 4.9 (2012). See also Winn v. Brown, 8 Vet. App. 510, 516 (1996) (stating that congenital or developmental defects are not diseases or injuries within the meaning of VA law and regulation). However, VA's General Counsel has held that a congenital defect can be subject to superimposed disease or injury, and if that superimposed disease or injury occurs during military service, service-connection may be warranted for the resultant disability. VAOPGCPREC 82-90 (July 18, 1990). The presumption of soundness, however, does not apply when a condition is a congenital or developmental defect, as service connection cannot be granted for such disorder. See Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993) (noting the difference between defect and disease and further noting that service connection may be granted if the congenital or developmental condition is a disease). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if: (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau, 492 F.3d 1372, at 1376-77. When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d 1372, at 1376-77 . The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 Fed. Cir. 1997), cert. denied, 523 U.S. 104 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The record before the Board contains numerous post-service treatment records, which will be addressed as pertinent. Dela Cruz v. Principi, 15 Vet. App. 143, 148-49 (2001) (a discussion of all evidence by the Board is not required when the Board has supported its decision with thorough reasons and bases regarding the relevant evidence.) III. Service Connection for Gastrointestinal Disorders Neither of the Veteran's entrance examinations reflects that he experienced any symptomatology related to a gastrointestinal disorder prior to his period of service or that he had a gastrointestinal disorder that preexisted his active military service. During service in December 1976, the Veteran was admitted to the hospital for observation after complaining of abdominal pain. He was found to have an inflamed appendix and therefore underwent an appendectomy. One week later, due to complaints of continued abdominal pain and distention, he underwent a laparotomy which showed adhesions obstructing his small bowel. After approximately two weeks of postoperative care, the Veteran returned home and returned to duty in January 1977. In February 1977, the Veteran again reported worsening upper abdominal pains, vomiting, and no bowel movements. An NG tube was placed and he was started on IVs. After 48 hours, his bowel sounds returned and the obstruction was no longer seen on x-rays. However shortly thereafter the Veteran worsened and the physicians felt that the Veteran had a transient ileus; he was treated conservatively with an NG tube and IVs. After nine days of hospital care, he was discharged with a diagnosis of resolving partial small bowel obstruction. The Veteran's subsequent service treatment records indicate further treatment for abdominal pain, hematochezia, anal fissure, possible ileus, and constipation, in pertinent part, as reported in treatment notes dated in May 1977, July 1977, September 1977 (apparently inaccurately dated as '1976'), October 1977, December 1977, January 1978, April 1978, and February 1979. The claims folder does not contain an examination report upon discharge in July 1979. A December 1995 routine air contrast barium test revealed scattered diverticula without diverticulitis, but was normal otherwise. In August 1997, Dr. T. Marshall ordered a barium enema examination that revealed very limited colonic diverticulosis involving the distal descending and sigmoid colon. There were no radiographic signs of diverticulitis. In January 2001, VA received, in pertinent part, the Veteran's service connection claim for gastrointestinal disorders. The record contains private medical evidence beginning in October 2000 from the Veteran's private physician, Dr. S.T.R. of Southern Gastroenterology. In this regard, a February 2001 colonoscopy ordered by Dr. S.T.R. revealed a rectal polyp and diverticulosis. A March 2001 treatment note shows impressions of diarrhea, resolved; hyperplastic polyp; and diverticulosis. A treatment noted dated in March 2003 shows an impression of rectal bleeding. In May 2001, the Veteran underwent a VA general medical examination. He reported stomach pain of a cramping nature. He also reported frequent diarrhea, heartburn, and nausea. Lower gastrointestinal diagnosis was diverticulosis. In July 2001, the Veteran was referred for a proctosigmoidoscopy at the VA. However, the examiner noted that the Veteran had had a colonoscopy one month prior, and there was no history of hemorrhoids. Therefore, the examiner felt that the procedure was unnecessary. However, the examiner performed a rectal examination which was entirely normal. Inspection of the anal canal did not disclose any abnormality. According to a May 2005 medical statement, Dr. S.T.R., indicated that the Veteran was first seen in his office in October 2000, and currently carried diagnoses of, rectal polyp, internal hemorrhoids, and diverticulosis, in pertinent part. Dr. S.T.R. indicated that the Veteran requested a statement which addressed whether any of the Veteran's gastrointestinal disorders are related to service. Dr. S.T.R. opined that the Veteran's rectal disability seemed to be secondary to internal hemorrhoids. The physician also indicated that he could not conclusively prove that any of the Veteran's GI symptoms were linked to his in-service illnesses. During an October 2007 VA examination, the Veteran reported diarrhea and abdominal cramping, in pertinent part. The examiner noted prior diagnoses of hemorrhoids and a history of colon polyps. The examiner noted that the Veteran has lower gastrointestinal symptoms that were being followed by a private gastroenterologist. The examiner concluded that the symptoms were still being worked up and found no diagnosis fitting the Veteran's current symptoms. However, the RO determined that this digestive examination was inadequate for rating purposes and scheduled the Veteran for an additional one. A July 2008 VA examiner diagnosed the Veteran with hemorrhoids, colon polyps, and diverticulosis, in pertinent part, but found that there was nothing in the Veteran's service treatment records that could be considered consistent with these disabilities. The VA examiner stated that he would have to resort to mere speculation in order to say that the Veteran's in-service gastrointestinal complaints were a result of diverticulosis. In a November 2008 addendum report, the examiner was unable to state that a service-connected disability caused or chronically worsened the Veteran's current gastrointestinal disorders because the available information did not indicate any service-connected disabilities. Therefore, the Board, in its 2010 remand, requested an addendum medical opinion. In this regard, the Board, in pertinent part, asked that an examiner determine whether the Veteran has a gastrointestinal disorder that is proximately due to, the result of, or permanently aggravated by the Veteran's service-connected residuals of appendectomy and laparotomy with small bowel obstruction. In response, a December 2010 VA examiner specifically found no pathology, signs, or symptoms in the Veteran's gastrointestinal tract that might indicate any problems related to the in-service surgeries. She also noted that the Veteran had been treated for hiatal hernia with GERD, which she considered chronic and congenital disorder. In light of this, the Board requested additional medical commentary, concerning whether the gastrointestinal conditions were either congenital defects or congenital diseases. The Board asked several other questions regarding the etiology of the Veteran's upper gastrointestinal problems. First of all the Board asked that if the Veteran's hiatal hernia and/or GERD is a congenital or developmental defect, was it subject to, or aggravated by, a superimposed disease or injury during service which resulted in additional disability; or, was any increase in severity clearly and unmistakably due to the natural progress of the disorder; Secondly, if the Veteran's hiatal hernia and/or GERD is a congenital or developmental disease, the examiner was asked to state whether the disease clearly and unmistakably was manifest (i.e., an active disease process) prior to the Veteran's entry into active service. If so, was there clear and unmistakable evidence that there was there a permanent increase in the severity of the condition beyond its natural progression as a result of service. Thirdly, if the Veteran's hiatal hernia and/or GERD was found to be a congenital disease and there were no manifestations of the disease before service, was the onset (manifestation) of the disease in service; or was such disease otherwise related to service. Finally, if any current upper gastrointestinal disorder was not congenital or developmental in nature, was it at least as likely as not (probability of 50 percent or more) that any such disorder was incurred in or aggravated by any incident, disease, or injury during service. In February 2013, the VA examiner gave an addendum regarding the Veteran's upper gastrointestinal disorders. She stated: The veteran was found to have a hiatal hernia many years ago in 1995, 16 years after leaving active duty with no known trauma to account for the problem. It is often a congenital defect in that it involves a hole in the diaphragm that allows a loop of the stomach to enter the normally closed thoracic cavity. The defect is usually stationary in nature and rarely requires surgery to correct it. Therefore the veteran's hiatal hernia is more likely than not a congenital defect rather than a disease. Hiatal hernia is usually asymptomatic. So the fact that the veteran's condition was not found for many years is not particularly concerning. While it is within the realm of possibility that the hiatal hernia was the result of trauma or a lifting accident, there was inadequate evidence to cause the examiner to believe that this occurred while on duty. GERD can result from hiatal hernia when the herniated stomach forces stomach acid into the esophagus. This causes symptoms of heartburn, belching, regurgitation, sour taste in mouth etc. GERD is a disease rather than a congenital defect or developmental disease and can occur secondary to the hiatal hernia. By virtue of its pathology, it can wax and wane with variables of diet, weight, smoking, alcohol use, exercise, position, tight clothing, et.al. The examiner conducted a thorough chart review and noted the weight gain of 70 [pounds] since leaving active duty. Veteran on antihypertensives [drugs] consistently since around 1989 including beta blockers and other drugs that lower the LES [lower esophageal sphincter] pressure and induce GERD. There was an UGI performed prior to the bowel surgery in 1977, but since over 90 percent of all hiatal hernia is of the sliding type, the lack of findings does not exclude the problem. This still points to weight, medication, and advancing age as the most likely causes of increased symptomatology after leaving active duty. Increasing weight increases intraabdominal pressure which in turn affects the weakened lower esophageal sphincter and age causes weakness of the tissue. Beta blockers and other antihypertensives lower LES pressure as it relaxes the arterial system tissues to lower the blood pressure. There was no worsening of the congenital defect itself but worsening of the symptoms of GERD. No permanent aggravation of the underlying hiatal hernia or secondary GERD was found associated with his military service and there was nothing to suggest that the problem manifested itself while on active duty. According to Up To Date, an online medical service, "although neither hiatus hernia nor a hypotensive LES alone results in severe gastroesophageal junction incompetence, the two conditions interact with each other. This conclusion is consistent with the clinical experience that exercise, tight fitting garments, and activities involving bending at the waist exacerbate heartburn, especially after having consumed meals that reduce LES pressure." So symptoms worsen, [the] underlying condition does not. In regard to his hiatal hernia, the VA examiner found that it was a congenital defect. Consequently, the presumption of soundness does not apply and service connection is only warranted for the disorder if there was a superimposed disease or injury during service resulting in current disability. However, in this case, the VA examiner also categorically denied any causation or correlation between the Veteran's hiatal hernia and military service and/or the service connected bowel disability. She explained that while there may have been abdominal symptoms during service, this did not worsen the underlying disorder. In this regard, mere temporary or intermittent flare-ups of a pre-existing injury or disease during service are insufficient to be considered "aggravation in service", unless the underlying condition, itself, as contrasted with mere symptoms, has worsened. See Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); and Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Thus, the Board notes further, that as to the hiatal hernia, the examiner did not identify any superimposed disease or injury in service that would have resulted in current disability. A pre-existing disease or injury will be presumed to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity. Townsend v. Derwinski, 1 Vet. App. 408 (1991); 38 C.F.R. § 3.306(a). Evidence of the Veteran being asymptomatic on entry into service, even with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). So merely because the Veteran had stomach symptoms during service does not in turn mean the Board also has to conclude his hiatal hernia was permanently worsened as a consequence due to superimposed disease or injury. In other words, symptoms alone, does not obviate the need for the Veteran to still have supporting medical evidence confirming he has consequent disability, and in this particular instance this has to be evidence showing aggravation by way of superimposed disease of injury in service. And, unfortunately, in this particular instance the most probative, meaning competent and credible, evidence is against the claim. As far as the other diagnosed gastrointestinal disabilities to include GERD, the examiner has made it clear that this is neither a congenital defect nor congenital disease. In considering whether service connection is warranted on either a direct or secondary basis, the VA examiner also found this was not supported by the facts. While she noted that the GERD can be associated with a hiatal hernia, she explained "No...secondary GERD was found associated with his military service and there was nothing to suggest that the problem manifested itself while on active duty". In considering the Veteran's claim of secondary service by way of aggravation, in December 2010, she explained that the upper gastrointestinal problems were not affected by the surgery on the lower bowel. This is further strengthen by the fact that the service-connected disability has been rated as zero percent since service connection has been established. Furthermore, additional evidence of record supports this VA examiner's conclusion. In reviewing the Veteran's service as well as post-service history, there is no medical evidence either in service or in close proximity to service of any residual or increased disability associated with a hiatal hernia. In fact, there are no records reflecting complaints, diagnosis or findings related to gastrointestinal problems until 1997 or thereabouts, so for some 18 years after the Veteran's period of military service ended in July 1979. In fact, hiatal hernia and GERD were not diagnosed until October 2000. The Board realizes that the mere fact that there is no documentation of these conditions for years after service, such as in the way of treatment records, is not altogether dispositive of this claim, but it is nonetheless probative evidence to be considered in deciding this claim and may be viewed as evidence against it, especially when considering it on a direct basis. See Maxon v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); See, too, Mense v. Derwinski, 1 Vet. App. 354 (1991). In Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc) and Kahana v. Shinseki, 24 Vet. App. 428, 433, 438 (2011), the Federal Circuit Court and Veterans Court cautioned that negative evidence, meaning actual evidence weighing against a party, must not be equated with the absence of substantive evidence. But, ultimately, the Board must consider all the evidence relevant to the claim, including the availability of medical records, the nature and course of the disease or disability, the amount of time that has elapsed since military service, and any other pertinent facts. Cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact-finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). And, here, the VA compensation examiner, considered it noteworthy that there were no relevant findings of gastrointestinal complaints. The Board notes that in his testimony before the Board the Veteran reported that he has had continuing gastrointestinal problems since service. He is competent, even as a layman, to proclaim for example having experienced heartburn, vomiting and diarrhea since service. Indeed, he is even competent to make this proclamation absent any supporting contemporaneous medical evidence such as treatment records. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Veteran's statements however are of little probative value when weighed against the fact that he went many years without any documented complaint, much less treatment, for upper gastrointestinal problems after his military service had ended. In weighing the evidence, the Board has taken into consideration the Veteran's private patient profile that was self-reported in October 2000. At that time, he indicated that he had heartburn only since 1995, which is inconsistent with his current statements. Further, the Board reviewed his private records that date back to 1989. He complained of a variety of ailments but failed to complain of continuing abdominal problems. This tends to refute the notion that he had experienced continuous symptoms since service, such as in the manner alleged. These facts together, undermine his credibility insofar as whether he has had continued medical care since. See Macarubbo v. Gober, 10 Vet. App. 388 (1997). The Board also finds that the Veteran is not competent from a medical point of view to challenge the private physician's and VA examiner's conclusions that his gastrointestinal problems are unrelated to service. The VA examiner's opinion is well reasoned, and the examiner considered all relevant evidence both for and against the claim for the conclusion ultimately reached. The opinion therefore has the proper factual foundation and predicate, in turn giving it significant probative weight. See Elkins v. Brown, 5 Vet. App. 474 (1993); Black v. Brown, 5 Vet. App. 177 (1993). In this decision, the Board has considered all lay and medical evidence as it pertains to this claim. However, ultimately, the medical opinions are more competent and credible on the determinative issues of causation and aggravation. 38 C.F.R. § 3.159(a)(1) versus (a)(2). See, too, Buchanan, 451 F.3d 1331, 1335 (Fed. Cir. 2006) and Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (reiterating this axiom in a claim for rheumatic heart disease). For these reasons and bases, the preponderance of the evidence is against this claim for service connection for upper gastrointestinal disabilities on either on a direct or secondary basis. And since the preponderance of the evidence is against this claim, the benefit-of-the-doubt rule does not apply, and this claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). IV. Service Connection for Hypertension The Veteran also claims that service connection is warranted for hypertension as secondary to his service-connected residuals of an appendectomy and small bowel obstruction. The Veteran's STRs show that according to the December 1973 enlistment examination report his blood pressure reading was 132/74. On February 9, 1976, he was seen with complaints of headaches. On intake, his blood pressure readings were 142/98/94 and 142/98/96. He was given Tylenol. For the next 4 days his blood pressure readings were 124/72, 120/86, 120/84, and 118/80/78. On February 3, 1977 while hospitalized for the small bowel obstruction, his blood pressure readings were elevated at 136/92. In September 1977 (misdated as September 1976) while being treated for vomiting and nausea he had elevated readings of 136/98. For the remainder of service when his blood pressure readings were taken they were within normal range (December 1977, 112/82; June 1978, 120/80; May 1979, 130/80, 120/80). As mentioned there were is no discharge examination, of record. The post-service private medical records relate that during treatment for sinusitis, in January 1989, the Veteran was diagnosed with probable essential hypertension with a reading of 140/100. Thereafter, he was variously diagnosed with probable hypertension, borderline hypertension, mild hypertension, and eventually essential hypertension. The Veteran submitted an April 2005 statement from Dr. A. B, who stated, "[t]he review of [the Veteran's] medical records reveals that he was found to have elevated blood pressure since 1976. In a statement dated in March 2007, this physician stated "[t]his is to certify that [the Veteran's] medical records support the evidence of a diagnosis of [h]ypertension since 1976. A VA examination was conducted in October 2007. In reporting his history the Veteran reported that he had been treated for hypertension since 1979. The diagnosis was hypertension. In a November 2008 addendum, the physician commented that the STRs revealed that the Veteran was treated for 1 or 2 elevated blood pressure readings but when given 5 day blood pressure checks, they were normal. Significantly, the VA examiner did not clearly indicate whether the Veteran's hypertension was likely incurred in service or within one year of his separation from service. The Board in March 2010 remanded the case for an addendum opinion. In response to this remand, the VA examiner in January 2011 (December 2010 examination) opined that it was less likely than not that the Veteran's current hypertension was related to his military service or his in-service surgery. In arriving at this opinion, the examiner noted that the occasional elevated blood pressure reading in the Veteran's service records occurred around the time of his acute illness and surgery in 1976. However, the Board pointed out that the Veteran's service treatment notes show elevated blood pressure readings in February 1976, prior to his appendectomy and subsequent laparotomy in December 1976. As such, the Board found that the January 2011 opinion was supported by inaccurate rationale. It was also pointed out that the examiner did not address the March 2007 private opinion provided by Dr. A.B. in which he stated that the Veteran was diagnosed with hypertension in 1976, which was during service. Further, the nurse practitioner did not address the additional hypertension questions posed in the 2010 remand, such as whether the Veteran's hypertension was manifested within one year of his separation from service, or whether the Veteran's hypertension was permanently aggravated by the service-connected residuals of appendectomy and laparotomy with small bowel obstruction. The Board therefore found that the medical nexus opinion was inadequate for rating purposes, in turn necessitating additional medical comment on this determinative issue of causation or aggravation. In accordance with the Board's remand directive for additional medical comment on the etiology of the hypertension, the VA examiner provided an addendum in February 2013. In terms of the veteran's hypertension claim, the following is offered: A search of the medical literature was performed. The examiner was unable to find support for physiologic connection between chronic hypertension and bowel surgery, bowel surgery complications including adhesions, or the use of anesthetics, anesthesia for the surgery. Temporary elevations in blood pressure can occur with the use of some drugs, alcohol intake, certain types of tumors, smoking, activity, heat, pain, systemic illness, salt intake, et. al. and can occur as secondary to numerous medical conditions. According to Harrisons Textbook of medicine, volume 2, 18th edition, hypertension tends to be familial and "likely to be the consequence of an interaction between environmental and genetic factors. The prevalence of essential hypertension increases with age and young individuals with relatively high blood pressure readings are at increased risk for subsequent development of hypertension." The examiner could not find anything in the literature to support the veteran's contention that his hypertension was permanently aggravated by his bowel surgery for the same reasons as above. Hypertension is generally defined as consistent readings of BP elevations greater than 140/90 on at least three different occasions due to the natural variations involved in the measurements. Again pain, activity, room temperature, smoking, stress can all effect the BP on short term basis. The veteran's elevated blood pressures were noted when he was sick or in pain primarily. He had two elevated blood pressures on February 9, 1976 with orthostatic check (not 4 readings as veteran noted in documents he submitted). The third number in those readings was the pulse rate as orthostatic issues were suspected and this is part of the evaluation for that condition. The following week serial readings were all normal (less than 120/86) after the headache was gone, a fact that supports the elevated readings were in response to pain. The serial hypertension readings performed in May 1979 indicate normal readings at 138/86 and 120/80 and did not require treatment. While some readings taken during active duty indicate what is now called prehypertension (130s/80s), it should be noted that prehypertension is only a risk factor for the later development of hypertension, NOT a mild form of hypertension. The examiner is asked to reconcile Dr. B's letter stating that BP elevations were present in 1976 fails to note that external factors of illness, pain, stress, et.al. were present to allow for the natural temporary elevation. He also does not note serial BP readings were normal when [patient] was not in pain [or] when taken in series of several days. He does not tell us of abnormal labs or imaging that would support untreated hypertension as underlying diagnosis since no cardiomegaly or proteinuria was found. Although veteran recalls treatment for hypertension within a year of leaving active duty, no records were submitted that substantiated this claim and veteran seemed uncertain of which MD treated him. It seems unlikely that he would start treatment in 1976 but be off meds for a number of years with the same hypertensive readings 10 years later as this would be injurious to his health. Record show weight gain to 262 lb. from 208 lb. in 1977 while on active duty. His weight in 1989 around time of dx of HTN was around 245-250 lb. which would definitely increase his risk of developing high blood pressure. In summary, veteran appears to have risk factors for HTN while on active duty in his early 20s, but did not develop essential HTN until 10 years later when he gained weight and age. In deciding this claim, the Board must analyze the probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons and bases for rejecting or accepting any material evidence. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Obviously, this responsibility is more difficult when, as here, medical opinions diverge. And, at the same time, the Board is mindful that it cannot make its own independent medical determination and there must be plausible reasons for favoring one medical opinion over another. With this mind, and after considering the evidence both for and against the claim, the Board finds the statements of the private physician, Dr. A.B., less persuasive in light of the overall record and the opinion of the VA examiner, and to some extent the opinion of the VA physician who conducted the prior examination in 2007. As an initial matter, in reporting his diagnosis, Dr. A.B. did not submit any rationale supportive of his conclusion or discuss the criteria on which he had based his opinion. And while it is presumed his diagnosis of hypertension (including being present since 1976) was in accordance with accepted medical standards, this does not negate the need for him to actually discuss or explain how the hypertension had its onset in 1976, especially since the VA examiner gave a far more detailed and comprehensive report, in comparison, as to why the Veteran's hypertension is not directly or presumptively related to his military service, since not diagnosed at any time during his service or even for many years after his discharge, until 1989 or thereabouts at the earliest, and was not caused by his service-connected residuals of appendectomy and bowel obstruction and is not being aggravated by them, either, to warrant alternatively granting service connection on a secondary basis. And this is where most of the probative value of an opinion is derived, from the discussion of its underlying rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Indeed, even review of the claims file does not compensate for reasoned medical analysis and explanation of the opinion. A medical opinion is considered adequate, versus inadequate, when it is based upon consideration of the Veteran's prior medical history and examinations and describes the disability in sufficient detail so the Board's evaluation of the disability will be fully informed and permit the Board to weigh the probative value of the opinion against others. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). And to be adequate, a medical opinion must do more than merely state a conclusion regarding the etiology of the claimed disorder, instead, must also support the conclusion with sufficient rationale and explanation. Stefl, 21 Vet. App. at 124. The probative value of an opinion is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support [the] opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). This clinician who indicated the Veteran's hypertension had its onset in 1976 did not relate any clinical data or other evidence supporting this conclusion, whereas the VA examiner who concluded unfavorably cited specific clinical findings (such as numerous prior blood pressure readings) and history in the records reviewed and considered. There is no "treating physician rule" requiring the Board to give additional evidentiary weight to opinions of doctors that have had occasion to treat or evaluate the Veteran over time. See White v. Principi, 243 F.3d 1378 (Fed. Cir. 2001); Van Slack v. Brown, 5 Vet. App. 499, 502 (1993). Indeed, to the contrary, although the Board may not ignore the opinions of treating clinicians, the Board is free to discount the probative value of these statements so long as the Board provides adequate reasons and bases for doing this. Sanden v. Derwinski, 2 Vet. App. 97, 100 01 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164, 169 (1991). The VA examiner considered his relevant medical and other history, aside from the results of the personal clinical evaluation of the Veteran, and discussed his symptoms (or lack thereof) in the context of this history. The Board therefore gives substantial probative weight to the reports of the VA examiner due to her thorough review of the Veteran 's medical history, her discussion of his particular symptoms, her consideration of the theories presented, and her medical expertise. See Willis v. Derwinski, 1 Vet. App. 66, 70 (1991); Sklar v. Brown, 5 Vet. App. 140, 146 (1993). Otherwise, an opinion may be reduced in probative value, even where the statement comes from someone with medical training such as Dr. A.B., if the medical issue requires special knowledge. See Black v. Brown, 10 Vet. App. 279 (1997). The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The VA compensation examiner in this particular case thoroughly considered the possibility that the Veteran's current hypertension had its onset in service, within the one-year presumptive period following service, or alternatively was caused or aggravated by the service-connected disabilities, but ultimately rejected these notion based on reasonable medical principles that were supported by the medical and other evidence. See Wray v. Brown, 7 Vet. App. 488, 493 (1995) (holding that the adoption of an expert medical opinion may satisfy the Board's statutory requirement of an adequate statement of reasons and bases if the expert fairly considered the material evidence seemingly supporting the Veteran's position). Furthermore, the medical evidence supports this VA examiner's conclusions. In reviewing the Veteran's service as well as post-service history, there is no evidence showing elevated blood pressure (certainly not persistently elevated) or a diagnosis of hypertension in service or within a year of his discharge, and certainly not the required indication that it was at least 10-percent disabling. 38 C.F.R. § 4.71a , Diagnostic Code 7101. In fact, there are no records reflecting complaints, diagnosis or findings related to hypertension until 1989 or thereabouts, so for some 10 years after the Veteran's military service ended in 1979. This is far removed from his service with no suggestion of its initial manifestation during the still many intervening years following the conclusion of his service. The Board realizes that the mere fact that there is no documentation of this condition for so long after service, such as in the way of treatment records, is not altogether dispositive of this claim, but it is nonetheless probative evidence to be considered in deciding this claim and may be viewed as evidence against it, especially when considering it on direct and presumptive bases. See Maxon, supra. As noted above, when appropriate, the Board may consider the absence of evidence when engaging in a fact-finding role. And, here, the VA compensation examiner, considered it noteworthy that there were no relevant findings of elevated blood pressure besides when he was being treated for pain or even for many years afterwards, so well beyond the one-year presumptive period following service. As noted by the VA nurse practitioner, while the Veteran has reported treatment for hypertension since 1979, she found it highly unlikely in light of the objective findings noted during service and those found 10 years after service discharge. The Board finds the objective statement of the medical professional more credible in this case. Finally, the Board acknowledges that Walker, supra, stands for the proposition that continuity of symptomatology can aid in the substantiation of a claim where the diagnosis of chronic disability is questionable in service or within the first post-service year. Id. However, this is not such a case as there is no question of the assessment of hypertension in service as none was made and VA examination has indicated that the Veteran's elevated blood pressure readings were isolated and attributable to acute illness. Moreover, as explained above, the evidence does not substantiate the assessment or observation of hypertension within the first post-service year. Id. Further, although lay persons are competent to provide opinions on some medical issues, see Kahana, supra, the specific issue in this case, hypertension, falls outside the realm of common knowledge of a lay person. See Jandreau, supra. For these reasons and bases, the preponderance of the evidence is against this claim for service connection for hypertension. And since the preponderance of the evidence is against this claim, the benefit-of-the-doubt rule does not apply, and this claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER The claim for service connection for an upper gastrointestinal disorder is denied. The claim for service connection for hypertension is denied. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs