Citation Nr: 1325160 Decision Date: 08/08/13 Archive Date: 08/13/13 DOCKET NO. 10-11 048 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for gastroesophageal reflux disease (GERD) and Barrett's esophagus. REPRESENTATION Appellant represented by: Tennessee Department of Veterans' Affairs ATTORNEY FOR THE BOARD Timothy D. Rudy, Counsel INTRODUCTION The Veteran served on active duty from October 1965 to October 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In March 2010, the Veteran requested a hearing before a Veterans Law Judge be held at the RO. In April 2013 correspondence, the RO informed the Veteran that a Board hearing had been scheduled for a date in May 2013. However, the Veteran's representative notified VA in writing that the Veteran wanted to withdraw the request for the scheduled Board hearing. Therefore, his request for a Board hearing is deemed withdrawn. 38 C.F.R. § 20.702(e) (2012). FINDING OF FACT The preponderance of the evidence of record indicates that GERD with Barrett's esophagus was not incurred in or aggravated by service or caused by or aggravated by his service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for GERD and Barrett's esophagus, secondary to service-connected PTSD, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in line of duty or for aggravation of preexisting injury suffered or disease contracted in line of duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). Generally, in order to prevail on the issue of direct service connection on the merits, there must be evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). A veteran seeking disability benefits must establish the existence of a disability and a connection between service and the disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Secondary service connection shall be awarded when a disability is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (2012); Libertine v. Brown, 9 Vet. App. 521 (1996); Harder v. Brown, 5 Vet. App. 183 (1993). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable. Establishing service connection on a secondary basis therefore requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service connected disability. 38 C.F.R. § 3.310(a) (2012); Allen v. Brown, 7 Vet. App. 439 (1995). 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. The Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record. Every item of evidence does not have the same probative value. The Veteran seeks service connection for his GERD with Barrett's esophagus, to include as secondary to service-connected PTSD. In written submissions, the Veteran contends that his VA examination was inadequate because the examiner only asked him a few questions, checked his heart and blood pressure, never looked at his throat, told him he did not need to take the test, and that all the information she needed was on the computer. He also submitted a Board decision from several years ago that shows an award of service connection for GERD secondary to PTSD and a letter from his private physician explaining that it was "certainly possible" that the Veteran's GERD with Barrett's esophagus was caused by or aggravated by his military service and the PTSD. The Veteran's service separation form indicates that the Veteran served in the Republic of South Vietnam where he received the Combat Infantryman Badge. The service medical records show no complaints of, or treatment for, any GERD or Barrett's esophagus. However, an April 1966 service treatment record shows that the Veteran fainted in the field and that he had mild abdominal cramping and had diarrhea for two days. His June 1967 discharge examination found no abnormalities of the abdominal system and viscera. After service, private medical records from Keeler Bay Family Practice show onset of GERD in June 1998 and onset of Barrett's esophagus in October 1998. A March 2002 private medical record shows an assessment of Barrett's esophagus. An October 1998 letter from the Veteran's private gastroenterologist notes that recent biopsies from his esophagus showed only changes consistent with reflux esophagitis. It was recommended that the Veteran continue taking Prilosec indefinitely to control his symptoms. A July 2003 private EGD showed an esophageal web at the esophagus with an otherwise normal esophagus. In a July 2007 letter from the Veteran's physician, Dr. D.H., it was noted that the Veteran had been followed since 1988 for GERD with Barrett's esophagus, among other disorders. Dr. D.H. stated that it was certainly possible that the GERD with Barrett's esophagus was caused by or aggravated by the Veteran's service and his PTSD. Dr. D.H. stated that it was well known that GERD could be aggravated, initiated, or associated with PTSD. An August 2008 VA medical record shows that the Veteran had had two episodes of food becoming stuck in his esophagus, that he had esophageal dilation in the past, and that he was taking Omeprazole. There were no complaints of dysphagia or reflux while he took the drug. The Veteran was granted service connection for PTSD in a November 2008 rating decision. A May 2009 VA medical record shows an assessment of GERD. The Veteran underwent a VA examination in October 2009. After a review of the claims file, the VA examiner noted that the Veteran was diagnosed with GERD during a routine medical examination and that the date of onset of his Barrett's esophagus was unknown. There was no history of heartburn, regurgitation, or dysphagia. The VA examiner opined that GERD was not caused by or a result of PTSD. The examiner noted that the GERD and Barrett's esophagus had been diagnosed since at least 1998 and that during that 10-year period the Veteran's symptoms had been managed with the same medication at the same dose. The VA examiner commented that if the Veteran's PTSD was a cause of or aggravated the Veteran's GERD, then it would be reasonable to expect the symptoms to worsen over time, but that was not the case. The examiner also noted that GERD was fairly common in the general population due to a failure of the cardia, which the examiner thought probably explained the cause of the Veteran's GERD. In a February 2010 signed statement the Veteran contended that his PTSD was diagnosed before his GERD and Barrett's esophagus were diagnosed and controlled by preventative medication in approximately 1995. A May 2011 private medical record noted that the Veteran complained of dysphagia. Based on the evidence of record the Board finds that the preponderance of the evidence is against a finding that GERD or Barrett's esophagus was incurred in or aggravated by service or is due to, the result of, or aggravated by service-connected PTSD. Initially, the Board notes that there is no medical evidence of GERD or Barrett's esophagus during service. And there is no competent evidence of record relating those disabilities to the Veteran's service or to any event, disease, or injury during service. Therefore, the Board finds that the preponderance of the evidence is against a finding that GERD or Barrett's esophagus was incurred during active service. However, because the Veteran has already been granted service connection for PTSD, secondary service connection is available for GERD and Barrett's esophagus if the evidence shows that the GERD or Barrett's esophagus disorder was either caused by or aggravated by his service-connected PTSD. The October 2009 VA examiner found that such a relationship was not present because the Veteran always took the same dose of the same medication for his GERD after it was diagnosed in 1998 and that it was diagnosed before the Veteran's PTSD. However, the Veteran's private physician, Dr. D.H., found that it was "certainly possible" that the Veteran's GERD with Barrett's esophagus disorder was caused by or aggravated by his PTSD because. That physician maintained, it was well known that type of disorder can be aggravated, initiated, or associated in some way with PTSD. The Board finds that the VA examination is more persuasive that the private medical opinion. The private medical opinion found that a relationship between GERD or Barrett's esophagitis and service was "certainly possible" and it was medically known that type of disorder can be aggravated or initiated by PTSD. However, that opinion is speculative in nature, noting only a possibility of relationship without showing that it was at least as likely as not that GERD or Barrett's esophagitis was due to or aggravated by PTSD. Obert v. Brown, 5 Vet. App. 30 (1993); Tirpak v. Derwinski, 2 Vet. App. 609 (1992); Davis v. West, 13 Vet. App. 178 (1999); Bostain v. West, 11 Vet. App. 124 (1998); Beausoleil v. Brown, 8 Vet. App. 459 (1996). The Board finds that the VA examination is more persuasive because of the rationale provided and the consideration of the severity of the disability, which was not shown to have increased. The examiner discussed and recited medical research conducted into the causes of GERD and provided a rationale for finding that GERD and Barrett's esophagus were not caused or aggravated by PTSD. The Veteran is competent to report that he has experienced symptoms, of which he has personal knowledge. However, the diagnosis and etiology of GERD and Barrett's esophagus are not simple matters capable of lay observation. Those findings require medical training. Therefore, the Veteran is not competent to offer an opinion regarding diagnosis or etiology of GERD or Barrett's esophagus. Layno v. Brown, 6 Vet. App. 465 (1994); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, the Board finds that preponderance of the evidence is against a finding that GERD or Barrett's esophagus was incurred in or aggravated by service, or is due to or aggravated by service-connected PTSD. Therefore, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for GERD and Barrett's esophagus, to include as secondary to service-connected PTSD, is denied. ____________________________________________ HARVEY P. ROBERTS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs