Citation Nr: 1327799 Decision Date: 08/30/13 Archive Date: 09/05/13 DOCKET NO. 11-03 018 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for gastroparesis, claimed as secondary to medication for treatment of service-connected left ankle and bilateral knee disabilities. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD James A. DeFrank, Counsel INTRODUCTION The Veteran had service in the Army Reserves from December 1989 to August 1990. This case comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which, in part, denied service connection for gastroparesis. In July 2011, the Veteran testified at a Board hearing held at the VA Central Office in Washington, DC. A transcript of the hearing has been associated with the claims file. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Board finds that additional development is required, as discussed below. Under 38 C.F.R. § 3.310(a), service connection may be granted for disability that is proximately due to or the result of a service- connected disease or injury. That regulation permits service connection not only for disability caused by service- connected disability, but for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See 38 C.F.R. § 3.310 (2012). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002). The evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). The threshold for finding a link between current disability and disease or injury in service is low. McLendon v. Nicholson, 20 Vet. App. 79 (2006). If the medical evidence of record is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board is always free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions. However, it is not free to substitute its own judgment for that of such an expert. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). In this case, the Veteran claims that her current gastroparesis is the result of his medication that she takes for her service-connected left ankle and bilateral knee disabilities. The Veteran underwent a VA examination in December 2010. The examiner opined that it was less likely as not that the Veteran's gastric paresis was due to pain medication. The examiner noted that after presenting with a recurrence of symptoms in June 2009, the Veteran received a gastric pacemaker in May 2010 with an 80 percent improvement in her gastric paresis. The examiner concluded that the gastricparesis was secondary to pyloric stenosis that was treated with Botox injections. The gastroparesis improved her symptoms status post Botox injection of pylorus. While the December 2010 VA examiner attributed the Veteran's gastroparesis to her pyloric stenosis, the Veteran and her representative at the July 2011 hearing noted that instances of pyloric stenosis initially diagnosed in adults are incredibly rare. The Veteran also noted that she never had any stomach difficulties as a baby, during her childhood or in basic training and that she was allergic to opiates as her entrance examination noted that she was allergic to codeine. The Veteran testified that she took Motrin, Darvon, Oxycodone, Vicodin and Percocet for her service-connected left ankle disability. In support of her claim, the Veteran has submitted multiple internet articles which indicate that cases of idiopathic hypertrophic pyloric stenosis are extremely rare. Notably, a submitted article indicated that the adult variant of pyloric stenosis had "less than 200 cases reported in the English literature" while another article noted that this "condition was usually diagnosed before the baby is 6 months old". Yet another internet article also noted that risk factors for gastroparesis were "certain medications that slow the rate of stomach emptying, such as narcotic pain medications and antidepressants". Given the recently submitted internet articles associating gastroparesis with pain medications and the articles which indicate the rarity of pyloric stenosis in adults, the Board believes that a more detailed rationale and opinion is required despite the December 2010 VA examiner's findings that it was less likely as not that the Veteran's gastric paresis was due to pain medication. Additionally, the Veteran also testified that she attempted to avoid taking medications for service-connected disabilities as they made her gastroparesis worse. The Board again notes that 38 C.F.R. § 3.310(a) permits service connection not only for disability caused by service-connected disability, but for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See Allen, supra. While the December 2010 VA examiner determined that it was less likely as not that the Veteran's gastric paresis was due to pain medication, the examiner did not address whether the medications taken for the service-connected left ankle and bilateral knee disabilities have aggravated her gastroparesis. See 38 C.F.R. § 3.310; Allen, supra. Therefore, the Board finds that the evidence currently of record is insufficient to resolve the claim for service connection for gastroparesis, as secondary to medication for treatment of service-connected left ankle and bilateral knee disabilities, and that further medical examination and opinion in connection with this claim are warranted. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c) (4). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated her for the disability on appeal. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. Appropriate efforts must be made to obtain all available VA treatment records. All attempts to procure records should be documented in the file. If the AMC/RO cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran is to be notified of unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit those records for VA review. 2. Thereafter, schedule the Veteran for appropriate VA examination addressing the contended causal relationship between gastroparesis and medication for treatment of service-connected left ankle and bilateral knee disabilities. The claims file must be provided to the examiner(s) for review. Based on the results of the Veteran's examination and a review of the claims file, the examiner should be asked to opine whether it is at least as likely as not that current gastroparesis was caused or aggravated (made permanently worse) by the medication for treatment of service-connected residuals left ankle and bilateral knee disabilities. In making this determination, the examiner should specifically address the internet articles in the claims file which note the rarity of cases of pyloric stenosis in adults as well as the documented risk factors of gastroparesis. The rationale for all opinions expressed must be provided. If the examiner cannot respond without resorting to speculation, he should explain why a response would be speculative. 3. Thereafter, readjudicate the claim. If the determinations remain unfavorable to the Veteran, issue a supplemental statement of the case before returning the case to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ C. TRUEBA Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).