Citation Nr: 1332946 Decision Date: 10/22/13 Archive Date: 10/24/13 DOCKET NO. 10-14 637 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for gastrointestinal disability, to include gastroesophageal reflux disease (GERD) and peptic ulcer disease. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Willie E. Spruill, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1966 to December 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The record before the Board consists of the Veteran's paper claims file and an electronic record known as Virtual VA. In light of the evidence of record, the Board has construed the Veteran's claim for service connection for a stomach disability to include GERD, peptic ulcer disease, and any other gastrointestinal disorders. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). REMAND Following its review of the record, the Board has determined that further development of the record is required before the Board decides the Veteran's claim. A new VA examination and opinion are warranted. Specifically, in October 2008, a VA examination was conducted to determine whether the Veteran's stomach disability was caused or permanently worsened by the service-connected psychoneurotic anxiety reaction with psychophysiological gastrointestinal reactions. The examiner concluded that due to the Veteran's "strong family history of gastrological illness," increase in weight, and dietary considerations, the Veteran's GERD is less likely than not caused by his service-connected disorder. In a July 2009 VA examination report, the VA examiner opined that given the Veteran's family history, existence of stomach trouble prior to service, self medication with baking soda, and a medical board's determination of no permanent aggravation by service, the Veteran's GERD with gastritis was related to his pre-existing stomach trouble. However, the evidence of record does not reflect that the Veteran has a strong family history of gastrointestinal problems, and the Veteran has denied such a history. Further, after the Veteran was hospitalized in service for an ulcer, the medical board found that the Veteran's preexisting gastrointestinal syndrome, manifested by a history of gastric ulcer, was in fact aggravated by service, which conflicts with the examiner's findings. Moreover, the examiner did not address whether the Veteran's GERD has been aggravated by his service-connected disorder. The examination report also did not address whether the Veteran has other gastrointestinal disorders including peptic ulcer disease, that are etiologically related to service or other gastrointestinal disorders that were caused or permanently worsened by the service-connected anxiety disorder with associated gastrointestinal reactions. In this regard, a June 2008 letter from Dr. R.B., the Veteran's private doctor, states that the Veteran has a long-standing history of peptic ulcer disease since service. Although the Veteran's gastric ulcer disease during service was found to have resolved by X-ray, a September 1968 gastrology consultation report reflects a diagnosis of chronic peptic disease and notes that the Veteran had not been symptom free at any time except while hospitalized. VA has defined peptic ulcers as chronic diseases under § 3.309(a) (2013), which are subject to the relaxed evidentiary provisions of § 3.303(b) and § 3.307 of the regulations. Thus, the October 2008 and July 2009 VA medical opinions are not sufficient to make an informed decision on this claim. Accordingly, the claim must be remanded for a new opinion that addresses these issues. A new notice letter under the Veterans Claims Assistance Act of 2000 (VCAA) should also be sent to the Veteran. Although the RO provided the Veteran notice of the evidence required to substantiate a service-connection claim on a secondary basis in an October 2008 letter, it does not appear that any notice of the evidence required to establish service connection on a direct basis has been sent to him. Moreover, because the claim has been expanded to include other gastrointestinal disorders, the notice letter should inform him of the requirements for substantiating a service connection claim for all current gastrointestinal disorders, on a direct and secondary basis. Private medical records show that the Veteran received treatment for gastrointestinal disorders from Dr. R.B. The originating agency should obtain recent pertinent records from Dr. R.B. at the Boulware Medical Center. It should also obtain outstanding VA treatment records dating from December 2008 forward. Accordingly, this case is REMANDED to the RO or the Appeals Management Center (AMC), in Washington, D.C., for the following actions: 1. Provide the Veteran a VCAA notice letter informing him of the requirements for substantiating his claim of service connection for gastrointestinal disability, to include GERD and peptic ulcer disease, on a direct and secondary basis, and informing him of the respective duties of VA and the Veteran in obtaining evidence. 2. Undertake appropriate development to obtain all outstanding records pertinent to the Veteran's claim, to include recent records from Dr. R.B. at Boulware Medical Center and any outstanding VA treatment records dating from December 2008 forward. 3. Then, the Veteran should be afforded a VA examination by a physician with sufficient expertise to determine the nature and etiology of all gastrointestinal disorders present during the period of the claim. The claims file and any pertinent evidence in Virtual VA that is not contained in the claims file must be made available to and reviewed by the examiner, and any indicated studies should be performed. Based upon the examination results and the review of the Veteran's pertinent history, the examiner should identify all gastrointestinal disorders present during the period of the claim. With respect to each such disorder, the examiner should state an opinion as to whether there is a 50 percent or better probability that the disorder was present in service and if so, an opinion as to whether the disorder clearly and unmistakably existed prior to the Veteran's entrance onto active duty. With respect to each gastrointestinal disorder present during the period of the claim that the examiner believes existed prior to the Veteran's entrance onto active duty, the examiner should state an opinion as to whether the disorder clearly and unmistakably underwent no permanent increase in severity during or as a result of service. With respect to each gastrointestinal disorder present during the period of the claim that the examiner believes was not present during service, the examiner should state an opinion as to whether there a 50 percent or better probability that the disorder is etiologically related to the Veteran's active service. With respect to each gastrointestinal disorder present during the period of the claim that the examiner believes was not present during service and is not etiologically related to service, the examiner should state an opinion as to whether there is a 50 percent or better probability that the disorder was caused or permanently worsened by the service-connected psychoneurotic anxiety reaction, psychophysiological gastrointestinal reactions. The examiner must provide a complete rationale for each opinion expressed. If the examiner is unable to provide any requested opinion, he or she should explain why. If an opinion cannot be made without resort to speculation, the examiner is to provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 4. The RO or the AMC should also undertake any other development it determines to be warranted. 5. Then, the RO or the AMC should readjudicate the issue on appeal. If any benefit sought on appeal is not granted to the Veteran's satisfaction, provide the Veteran and his representative a supplemental statement of the case and afford them the requisite opportunity to respond before returning the case to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. The Veteran need take no action until he is otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON NEXT PAGE) This REMAND must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). _________________________________________________ Shane A. Durkin 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) (2013).