Citation Nr: 1328080 Decision Date: 09/03/13 Archive Date: 09/10/13 DOCKET NO. 98-19 107 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to service connection for ulcerative colitis, to include as secondary to service-connected hemorrhoids. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD L. A. Rein, Counsel INTRODUCTION The Veteran served on active duty from December 1971 to February 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. The Veteran has been afforded three Board hearings-in June 2003, March 2008, and March 2012 before three different Veterans Law Judges (VLJs). See Arneson v. Shinseki, 24 Vet. App. 379 (2011). Thus, panel below will participate in the Board's decision regarding the claim on appeal. See 38 C.F.R. § 20.700(a) (2012). This appeal was previously before the Board in January 2004, at which time it was remanded in pertinent part to obtain outstanding VA treatment records; to obtain a VA examination; and to provide proper notice. This appeal was again before the Board in March 2006, at which time it was remanded to address the theory of service connection for ulcerative colitis on a secondary basis in a statement of the case. This appeal was next before the Board in July 2008, at which time the issue was clarified as whether new and material evidence had been received. The issue was remanded in order to obtain outstanding Social Security disability records. This appeal was again before the Board in April 2009, at which time it was remanded in order to provide the Veteran appropriate notice regarding the pre-2001 definitions of new and material evidence, and the reasons that his claim had been previously denied. The appeal was, however, again remanded in March 2010 because the June 2009 notice issued by VA was inadequate. This appeal was remanded again in November 2011, this time to afford the Veteran a hearing before a third Veterans Law Judge. In August 2012, the Board reopened the claim of service connection for ulcerative colitis and remanded it for further development, including a VA examination addressing the several theories involved in this case, which was accomplished. In May 2013, the Board again remanded this matter for additional development. FINDINGS OF FACT 1. Service connection is in effect for internal hemorrhoids with external tags (hemorrhoids), which is evaluated as 10 percent disabling. 2. The preponderance of the evidence shows that the Veteran's ulcerative colitis was not present in service or until many years thereafter and was neither caused nor aggravated by service or an incident of service origin, including to his service-connected hemorrhoids. CONCLUSION OF LAW The criteria for service connection for ulcerative colitis, to include as secondary to service-connected hemorrhoids, are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1154(a), 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012); 38 C.F.R. § 3.310 (2006). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to notify and assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letters dated in May 2002, February 2004, August 2006, July 2010 and May 2013. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and his representative suggest actual knowledge of the elements necessary to substantiate the claim. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the adjudication in the most recent June 2013 supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. The Board notes that in a May 2013 notice letter, the Veteran was requested to provide the contact information for Dr. Alfred McNair, and the dates he was treated for, VA to obtain his medical records. In this regard, during the October 2012 VA examination, the Veteran indicated that Dr. McNair determined that the Veteran had ulcerative colitis prior to 1984 and that there were potential outstanding medical records. However, to date, neither the Veteran nor his representative have responded with information an authorization necessary to obtain these records or have submitted them to VA for consideration. Although pursuant to 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012) VA is required to make reasonable efforts to assist a claimant in obtaining evidence to substantiate his claim for benefits so long as he "adequately identifies those records and authorizes the Secretary to obtain them," the Veteran has the ultimate responsibility to locate and secure the records, and VA is under no duty to obtain records for which the Veteran has not provided an authorization as he cannot remain in a passive role. See Hyatt v. Nicholson, 21 Vet. App. 390, 394-95 (2007); Loving v. Nicholson, 19 Vet. App. 96, 102 (2005). VA has also obtained several examinations with respect to the claim on appeal. In addition, the Veteran has provided testimony before RO personnel and three Veterans Law Judges; transcripts of each are associated with the claims file. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Finally, during this appeal the Veteran was afforded several hearings before VLJs and an RO Decision Review Officer (DRO) in which he presented oral argument in support of his claim. 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 VLJ and DRO 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, during the hearing, the VLJs and DRO did not always note the bases of the prior determinations or the elements that were lacking to substantiate the claim. The VLJs and DRO, however, asked specific questions directed at identifying whether the Veteran's ulcerative colitis was related to or had its onset in service or was caused or aggravated by his service-connected hemorrhoids. The VLJs and DRO sought to identify any pertinent evidence not currently associated with the claims, and further, the Veteran volunteered his treatment history and onset and treatment of his symptoms since service. Accordingly, the Veteran is not shown to be prejudiced on this basis. 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 the Board and DRO hearings. By contrast, the hearings focused on the elements necessary to substantiate the claim and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant, the VLJs and DROs complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). II. Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). That determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d) (2012). Where there is a chronic disease shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). When a condition noted during service is not shown to be chronic, or the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013) (noting that the continuity of symptomatology provisions apply only to the chronic disorders as listed in 38 C.F.R. § 3.309(a) ). In this case, as ulcerative colitis is not identified as a chronic disease under 38 C.F.R. § 3.309(a), 38 C.F.R. § 3.303(b) is inapplicable. Service connection may be granted for disability proximately due to or the result of a service-connected disability and where aggravation of a nonservice-connected disorder is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Effective October 10, 2006, 38 C.F.R. § 3.310 was amended to codify the Court's holding in Allen, which relates to secondary service connection on the basis of the aggravation of a nonservice-connected disorder by service-connected disability. See 71 Fed. Reg. 52744 (2006). The amendment essentially requires that a baseline level of severity of the nonservice-connected disease or injury must be established by medical evidence created before the onset of aggravation. Because the Veteran's claim was filed prior to the revision of the regulation, which is not liberalizing, the Board will adjudicate this claim under the former criteria set forth in 38 C.F.R. § 3.310. Service treatment records (STRs) show that the Veteran was treated for hemorrhoids, and that he reported experiencing bleeding, and severe anal pain. However, STRs are negative for complaints, findings, or diagnosis of ulcerative colitis. Post-service evidence includes a September 1978 treatment note that indicating that the Veteran noticed bright blood in his stools. At that time he reported experiencing severe upper quadrant pain, with nausea and occasional vomiting. In October 1978 the Veteran indicated that he had a history of nervous stomach. A February 1981 treatment note indicated that blood had been noticed in the Veteran's stool. A hospitalization record from July 1981 indicated that the Veteran reported experiencing pain in his rectum. He indicated that he had a hemorrhoid operation in 1973, and diagnosis was of an anal fissure. An October 1984 proctosigmoidoscopy indicated that it was advanced the full 20 centimeters with some difficulty secondary to rectal pain and a large amount of fluid retained in the colon. Findings were of severe mucosal inflammation at 18 centimeters (friable with some bleeding). Inflammation was noted at 14 centimeters. Two small internal hemorrhoids were also observed. Inflammatory bowel disease probably representing ulcerative colitis was diagnosed. Treatment note from January 1985 shows that the Veteran reported a history of ulcerative colitis and vomiting, and was diagnosed as having a viral urinary tract infection. Hospitalization records from January 1985 show that the Veteran reported a history of cramping and red mucous stools. His symptoms had reportedly progressed over several years. A year earlier he had been diagnosed as having ulcerative colitis while admitted at Hinds General Hospital. The Veteran reported that he only had blood in his stools since his admission. Two to three years prior to his admission the Veteran reported that he had been to a VA hospital for increased rectal bleeding, and a protoscopy showed negative results. The Veteran had been on steroids since his October hospital admission, and reportedly had not experienced bleeding for the previous two weeks. The Veteran experienced no nausea, vomiting or hematemesis. On examination the Veteran's abdomen had diffuse tenderness to palpation and positive bowel sounds. Rectal examination showed external hemorrhoids, normal prostate which was nontender, and a heme-test was negative. A protoscopy was performed and colonoscopy showed erythematous cecym, no truly friable mucosa, no ulcers, no active disease; consistent with burned out ulcerative colitis. A VA examination in January 1985 indicated that the Veteran's rectum was not tight. In addition there had been three to four weeks of reported bleeding. Diagnosis was of colitis with a history of bleeding. A September 1988 VA treatment note states that the Veteran had ulcerative colitis (proctitis), with symptoms for 15 years. The Veteran continued to have some bright red blood, and mucous in his stools, and had loose stools approximately twice a week. A VA treatment note from October indicated that the Veteran reported he had ulcerative colitis, with symptoms for 16 years. He reported experiencing abdominal cramping and loose stool at that time. A January 1989 VA note also references the Veteran's ulcerative colitis as present for 15 years. An April 1989 treatment report shows that the Veteran was admitted to the hospital with abdominal pain and increasing number of stools, to include with bright red blood. Another flexible sigmoidoscopy showed ulcerative colitis. VA treatment records from 1991 to 1993 continue to show treatment for ulcerative colitis. A March 1993 treatment note shows that the Veteran reported experiencing rectal "fullness" as if he had to defecate all the time. He also reported having a foul-smelling stool and rectal seepage. He indicated that this started with a fall on a metal piece on his buttocks in 1972, and linked this to the development of his hemorrhoids. The Veteran indicated that he still had red blood streaking traces and mucous in his stools, as well as intermittent diarrhea. Past medical history recorded that he had ulcerative colitis diagnosed in 1972 with intermittent bloody stools. The Board notes that this date of diagnosis is not supported by the medical evidence of record, but rather relates to the Veteran's reported origin of his symptoms. At a January 1994 hearing before a Decision Review Officer (DRO) the Veteran explained that in 1972 he had slipped on some snow and fallen, injuring his rectum on a metal piece. He reported that he was diagnosed as having hemorrhoids and the area became infected, and skin tags were eventually surgically removed. He stated that he was later sent to a specialist in Nuremburg, and informed that there was an internal injury, possibly hemorrhoids. The Veteran reported the bleeding continued for the next 20 years, referencing 1974. The Veteran indicated that in 1984 when the bleeding worsened, and he experienced rectal seepage, with a devastating smell he was finally diagnosed as having ulcerative colitis. The Veteran reported struggling with symptoms such as constant seepage, and excessive diarrhea. VA treatment records from 1995 to 1996 show that the Veteran continued to be treated for ulcerative colitis. A January 1996 note states that he had symptoms of ulcerative colitis for 23 years, and that ulcerative colitis had been documented for the previous 13 years. A February 1996 note indicated that he had been diagnosed in 1983, but had experienced symptoms and possibly active disease for 23 years. In March 1996 the Veteran was afforded a VA rectal examination. The diagnosis was of ulcerative colitis since 1984, on Prednisolone and Mesalamine to control his symptoms. In his July 1996 Substantive Appeal the Veteran emphasized that his colitis had been present for 23 years, and that his rectal bleeding should not just be equated with his hemorrhoids. He indicated that during colitis flare-ups, his hemorrhoids were also affected. He then asserted that his colitis was a result of his hemorrhoids. The Veteran was afforded a May 1997 Board hearing, wherein he discussed slipping on snow in service and falling and injuring his rectum. He testified that the doctors had treated him for hemorrhoids, but he had basically continued bleeding ever since that time. The Veteran reported that he had skin tags excised, that his injury had become infected, and that he eventually was sent to a specialist in Nuremburg. Twelve years after that injury with increasing bleeding, ulcerative colitis was diagnosed. He reported that the diagnosis was in 1983 at General Hinds Hospital. The Veteran described symptoms of blood, diarrhea, and mucus. A medical treatment record from May 1998 referenced the Veteran's ulcerative colitis since 1984, and hematochezia since 1972. A May 1998 hospital note indicated that a flexible sigmoidoscopy was performed and showed mild to moderate bleeding of some internal and external hemorrhoids, but no active signs of ulcerative colitis. Another May 1998 sigmoidoscopy revealed burnt-out colitis, mucosal changes, and edema. In June 1998 ulcerative colitis, exacerbation was noted, along with a reported history of ulcerative colitis since 1972, diagnosed in 1984. A July 1998 sigmoidoscopy revealed idiopathic ulcerative colitis, severe. An October 1998 sigmoidoscopy revealed chronic colitis. In a June 1998 hearing before a DRO, the Veteran indicated that he had experienced continuous bleeding for 26 years, which references 1972. In a June 1998 Board hearing considering an earlier effective date for service connected hemorrhoids, the Veteran mentioned his ulcerative colitis. He indicated that he had been injured in service, and was diagnosed as having hemorrhoids, and had skin tags removed which areas were later infected. He reported that he was eventually sent to a specialist in Nuremburg. The Veteran indicated that between 1974 and 1984 he had been to the VA Hospital in Jackson, Mississippi and had a proctoscope. He reported that this was a small rod that could only be inserted a short distance to see around the edges, and all that was evident was hemorrhoids. In contrast, he reported that at Hinds General Hospital in 1984 when he was scoped the doctor inserted the instrument to the end of his colon and worked his way down, and this resulted in his diagnosis of ulcerative colitis. At a May 1999 DRO hearing the Veteran again reported having continuous bleeding. He also relayed that he had injured his rectum when slipping in the snow and falling when he was attempting to close the hatch of an armored personnel vehicle. The Veteran again reported being diagnosed as having hemorrhoids, and had surgery on them, which did not heal properly and became infected. In a May 1999 VA examination for pension purposes the Veteran indicated that he had been diagnosed as having ulcerative colitis in 1983 or 1984, and that his bleeding started as early as 1972 or 1973. He reported that he was always told that his bleeding was from the hemorrhoids. He indicated that he had constant problems with ulcerative colitis, including diarrhea, blood and mucus. In a May 1999 examination for his hemorrhoids the Veteran reported that ever since his hemorrhoidectomy he had bled, for 27 years since 1973. He indicated that he had skin tags remaining and continued to bleed, but was then diagnosed as having ulcerative colitis. He reported that he currently bled with each stool, and was incontinent such that he wore a diaper. In July 1999 the Veteran wrote that he had experienced 27 years of rectal bleeding, with red and dark blood over the years. In May 2002 the Veteran wrote about his 1973 fall in service leading to his rectal injury, and the specialist who he visited in Nuremburg informing him that it had been a mistake for the doctors to perform surgery. He raised the issue of outstanding service treatment records, suggesting that the VA had not acquired the records of his injury. In August 2002 the Veteran indicated that he had first sought treatment at the VA in Jackson, Mississippi, in February 1974 for rectal bleeding, but that these records had not yet been obtained. He indicated that he had experienced discomfort and bleeding with bowel movements for approximately 30 years. October 2002 VA treatment notes showed that the Veteran reported experiencing diffuse abdominal pain, and bright red bloody stools, and mucous. November 2002 VA treatment notes showed that the Veteran had an exacerbation of his ulcerative colitis, and had been admitted at Forrest General for gastrointestinal bleeding and dehydration, then transferred to the VA for follow-up. At his June 2003 Board hearing the Veteran reported having bleeding since approximately 1973, and rectal pain that worsened to the point of his defecating on himself. He associated his problem as malodorous. He discussed an in-service injury to his rectum incurred when he fell from an armored personnel carrier on which he was closing the hatch and landed on the mount of a machine gun. The Veteran indicated that he had been diagnosed as having hemorrhoids, and had a surgical procedure, prior to being sent to a specialist in Nuremburg. The Veteran reported that the doctor at his separation examination advised him to seek VA treatment for hemorrhoids because he had rectal bleeding, and that he sought treatment in 1974. He reported that a little scope, approximately 8 to 12 inches long was placed in his rectum, and he was told he had internal hemorrhoids. He suggests that his colitis could not be seen with this scope given the blood flow and infection he had at the time. A March 2004 VA opinion regarding ulcerative colitis was sought and reflects that the Veteran had been diagnosed as having ulcerative colitis in 1984 although he reported having had symptoms in the 1970s. The examiner stated that since service, from 1974 to 1984 the Veteran indicated that he experienced recurrent bouts of cramping abdominal pain and intermittent rectal bleeding. This was attributed to hemorrhoids both in service and subsequently. The Veteran reported having had a proctoscope examination in 1981, but that it was negative for anything but hemorrhoids and healing fissure. The examiner indicated that one could not state with medical certainty whether it was as likely as not that the Veteran's ulcerative colitis was related to an in-service injury or incident. He indicated that the ramifications of the case were discussed with the gastrointestinal specialist in the medical center, and he stated that one very well could have experienced symptoms of early onset ulcerative colitis prior to 1984, which would have been manifested by symptoms of cramping abdominal pain, increased frequency of bowel movements, and intermittent bleeding. The examiner went on to indicate that this was not documented in the Veteran's available medical records from 1978 to 1984. The examiner indicated that hemorrhoids would have no effect upon one's ulcerative colitis either etiologically or by aggravating it. Symptoms with hemorrhoids would be pain and bleeding, which could mimic some of the symptoms of ulcerative colitis; however, there was no relationship between the two disease processes. In June 2005 the Veteran clarified that he fell onto the armored personnel carrier, and struck the mount of his machine gun, and incurred a rectal injury. At his March 2008 Board hearing the Veteran reported that he had experienced leakage from his rectum and bleeding since service. He was unsure if he had abdominal pain in service. He identified that he had experienced increased bowel movements in service. His contentions regarding an in-service injury and diagnosis and treatment for hemorrhoids were similar as at previous hearings. A November 2009 statement reflects the Veteran's report of experiencing bleeding from the rectum for the previous 30 years, which is another reference to 1972. At his March 2012 Board hearing the Veteran indicated that he had experienced bleeding and diarrhea in service. He reported that he had approximately 4 bowel movements a day following his injury. He was again unable to recall if he had experienced abdominal cramps. He indicated that mucous had been present in his stool in service, although at the time he had not known how to identify what he was seeing, and only later when a medical professional explained to him what was in his stool did he understand. At the hearing, the Veteran submitted an excerpt from the Merck Manual of Diagnosis and Therapy regarding ulcerative colitis and hemorrhoids. He highlighted portions emphasizing symptoms of ulcerative colitis such as bloody diarrhea, increased urgency to defecate, mild abdominal cramps, and blood and mucus evident in the stool. Although the record was held open for 60 days, a medical nexus opinion was not submitted. In October 2012, the Veteran was afforded another VA examination. The examiner concluded that the ulcerative colitis was not incurred in service or caused by in-service injury, event or illness. In explanation, the examiner noted that the first post-service documentation of ulcerative colitis was in 1984. He acknowledged that the Veteran reported having symptoms of ulcerative colitis as early as 1973, and noted that it was certainly possible that the ulcerative colitis began during that timeframe, but that it would be speculative to conclude that the ulcerative colitis in fact began then, in the absence of objective clinical findings. The examiner did note that he reviewed a "letter" from a treating gastroenterologist by the name of Dr. Alfred McNair, who reportedly indicated that the Veteran was first diagnosed with ulcerative colitis in 1974. The examiner indicated that if Dr. McNair's treating records of the Veteran could be obtained for review, this might clarify the matter of the onset. As to secondary service connection, the examiner concluded that the service-connected hemorrhoids did not cause the ulcerative colitis, noting that there is no basis in the "medical literature" to establish that hemorrhoids and the treatment for hemorrhoids causes such a disease. In May 2013, the Veteran was afforded an additional VA examination that was performed by October 2012 VA examiner. The examiner noted a comprehensive review of the claims file to include the Veteran's service treatment records and post service medical records. He noted that the Veteran ulcerative colitis was diagnosed in October 1984 based on a colonoscopy with biopsy. He noted that the first date that he was able to find of the Veteran complaining of rectal bleeding was in September 1978, but there was no additional records associated with this date. Based on his review of the claims file, the VA examiner concluded that it was negative otherwise for documentation of ulcerative colitis and rectal bleeding until the diagnosis was made in 1984, which was 10 years after discharge from service. The VA examiner noted his prior opinion from October 2012, and stated that he was unable to find a letter from Dr. McNair or his treatment records indicating that the Veteran was first diagnosed in 1974, although an October 1984 Hinds General Hospital reflects that Dr. McNair dictated that record. The VA examiner opined that it is not at least as likely as not that the Veteran's ulcerative colitis was etiologically related to service because he had no objective clinical data to support that conclusion. The record clearly documents that the Veteran had hemorrhoids during his service period. The clinical record does not support a diagnosis of ulcerative colitis until 1984 and there are no intercurrent records that provide objective evidence to support that diagnosis until then, based on the VA examiner's review of the record. As to the Veteran's statement that his problems began after he fell (in service) injuring his rectum, it is noted that there is no medical evidence that supports a direct cause relationship between the injury and ulcerative colitis. He further opined that it is not at least as likely as not that the Veteran's ulcerative colitis was chronically worsened (i.e. aggravated) by the Veteran's service-connected hemorrhoids, to include medications taken therefore. There is no medical evidence that supports that hemorrhoids cause or aggravate ulcerative colitis. Nor is there medical evidence that supports that the treatment of hemorrhoids causes ulcerative colitis. The Veteran was treated with standard therapy for his hemorrhoids, including lancing for thrombosed hemorrhoids, stool softeners, suppositories, and sitz baths. Medical evidence does not support that any of these treatments cause or aggravate ulcerative colitis. In this case, the Board finds that the preponderance of the evidence is against a finding of service connection for ulcerative colitis on both a direct or secondary basis. Initially, the Veteran is first shown to be diagnosed with ulcerative colitis in October 1984, as demonstrated after undergoing a colonoscopy, more than 13 years after discharge. Moreover, the only medical opinions addressing whether there is a relationship between the Veteran's ulcerative colitis and service, to include his service-connected hemorrhoids, weigh against the claim. The October 2012 VA examiner, who provided a more detailed rationale in a May 2013 opinion, opined that the Veteran's ulcerative colitis was not related to service and was not related to or aggravated by his service-connected hemorrhoid disability, to include any treatments undertaken. The Board finds that VA examiner's opinions constitute probative evidence on the medical nexus question based on review of the Veteran's documented medical history and assertions and physical examination as well as consideration of medical literature. The opinions provided clear rationales based on an accurate discussion of the evidence of record. Prejean v. West, 13 Vet. App. 444 (2000); Guerrieri v. Brown, 4 Vet. App. 467 (1993). Further, a March 2004 VA medical opinion supports the conclusions reached in the October 2012 and May 2013 VA examiner's reports. Significantly, neither the Veteran nor his representative has presented or identified any contrary medical opinion that supports the claim for service connection for ulcerative colitis on a direct, or secondary basis. The Board is not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Veteran is competent, as a lay person, to report symptoms of which he has personal knowledge, such as rectal bleeding. Layno v. Brown, 6 Vet. App. 465, 469 (1994). As a lay person, however, he is not competent to establish a medical diagnosis or show a medical etiology merely by his own assertions as such matters require medical expertise. See 38 C.F.R. § 3.159(a)(1) (2012). The specific issue in this case, the relationship between the Veteran's ulcerative colitis and service, to include his service-connected hemorrhoids, is a complex medical issue and thus is outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As a lay person, he does not have the education, training and experience to offer a medical diagnosis or an opinion as to the onset or etiology of this condition. See Kahana; see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (holding that "[l]ay evidence can be competent and sufficient to establish a diagnosis when ... a lay person is competent to identify the medical condition" and providing, as an example, that a layperson would be competent to identify a condition such as a broken leg, but would not be competent to identify a form of cancer); Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue). The Board points out that as the VA examiners indicated, observing rectal bleeding and/or having gastrointestinal symptoms does not equate to a diagnosis of ulcerative colitis. Moreover, the Veteran's report of having ulcerative colitis since service is also not credible given that it conflicts with the contemporaneous medical evidence. To reiterate, the Veteran's statements regarding his ulcerative colitis are insufficient to establish a nexus to service or his service-connected hemorrhoids. The Board finds that he is not competent to establish the etiology of his ulcerative colitis in the absence of specialized training. The Board finds the examiners' opinions more persuasive given the medical training of the examiners and the rationales for their conclusions. Lastly, to the extent that he reports a continuity of gastrointestinal symptoms that he represents as a continuity of ulcerative colitis symptomatology, the Board notes that, gastrointestinal symptoms are not synonomous with ulcerative colitis symptoms, and that in any event, ulcerative colitis is not a chronic condition within the meaning of VA regulations. As such, service connection based on continuity of symptomatology is inapplicable. See Walker. In reaching the above conclusions, the Board has not overlooked the literature submitted by the Veteran during the March 2012 Board hearing. The information submitted by the appellant only contains generic information regarding diagnosis and treatment of ulcerative colitis. The Board finds that this evidence is entitled to limited probative value as it is not supported by any definitive or concrete medical opinion that addresses this Veteran's case. Even in light of this evidence, the Board finds the competent medical evidence of record reflecting no relationship between the Veteran's ulcerative colitis and his service, or service-connected hemorrhoid disability, still outweighs any evidence or argument on file in support of a nexus. See Mattern v. West, 12 Vet. App. 222, 228 (1999) (generic texts, which do not address the facts in this particular case with any degree of medical certainty, do not amount to competent medical evidence). Accordingly, the Board finds that the preponderance of the evidence is against a finding that the Veteran's ulcerative colitis is related to service, to include as secondary to or aggravated by his service-connected hemorrhoid disability. As there is not an approximate balance of positive and negative evidence regarding the merits of the appellant's claim that would give rise to a reasonable doubt in favor of the appellant, 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 ulcerative colitis is denied. ____________________________ ____________________________ JAMES L. MARCH T. STEPHEN ECKERMAN Veterans Law Judge, Acting Veterans Law Judge, Board of Veterans' Appeals Board of Veterans' Appeals ________________________ STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Department of Veterans Affairs