Citation Nr: 1336332 Decision Date: 11/07/13 Archive Date: 11/13/13 DOCKET NO. 07-09 006 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for residuals of a right leg fracture. 2. Entitlement to service connection for a bilateral ankle disorder, to include as secondary to residuals of a right leg fracture. 3. Entitlement to service connection for a bilateral knee disorder, to include as secondary to residuals of a right leg fracture. 4. Entitlement to service connection for a bilateral hip disorder, to include as secondary to residuals of a right leg fracture. 5. Entitlement to service connection for a gastrointestinal disorder, to include as secondary to residuals of a right leg fracture. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. Mishalanie, Counsel INTRODUCTION The Veteran served on active duty from August 1974 to December 1975. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a November 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In February 2009, the Veteran testified at a videoconference hearing before the undersigned; a transcript of the hearing is of record. In September 2009 and November 2010, the Board remanded the claims for additional development. The development has been completed to the extent possible and the case has been returned to the Board for appellate review. The Veteran's paper claims file and electronic folder in Virtual VA and the Veterans Benefits Management System (VBMS) have been reviewed in conjunction with the disposition of the issues on appeal. The Board notes that additional evidence has been associated with the Veteran's electronic folder in Virtual VA that has not been considered by the Agency of Original Jurisdiction (AOJ) in connection with these claims; however, in April 2012, the Veteran waived his right to initial consideration of any additional evidence by the AOJ and requested expedited processing of his appeal. FINDINGS OF FACT 1. A right leg disability, to include residuals of a right leg fracture and arthritis, did not manifest in service or within one year of discharge from active duty, and there is no competent and credible evidence of a nexus between a current right leg disability and service. 2. The Veteran's current bilateral ankle disabilities, to include arthritis, did not manifest in service or within one year of discharge from active duty, are unrelated to service or to a disease or injury of service origin, and are not proximately due to or aggravated by a service-connected disability. 3. The Veteran's current bilateral knee disabilities, to include arthritis, did not manifest in service or within one year of discharge from active duty, are unrelated to service or to a disease or injury of service origin, and are not proximately due to or aggravated by a service-connected disability. 4. The Veteran's current bilateral hip disabilities, to include arthritis, did not manifest in service or within one year of discharge from active duty, are unrelated to service or to a disease or injury of service origin, and are not proximately due to or aggravated by a service-connected disability. 5. The Veteran's current gastrointestinal disorder, to include gastroesophageal reflux disease (GERD) and dyspepsia, did not manifest in service, is unrelated to service or to a disease or injury of service origin, and are not proximately due to or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. A right leg disability, to include residuals of a right leg fracture and arthritis, was not incurred in or aggravated by service and may not be presumed to be related to service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 2. Bilateral ankle disabilities, to include arthritis, were not incurred in or aggravated by service, may not be presumed to be related to service, and are not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2013). 3. Bilateral knee disabilities, to include arthritis, were not incurred in or aggravated by service, may not be presumed to be related to service, and are not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2013). 4. Bilateral hip disabilities, to include arthritis, were not incurred in or aggravated by service, may not be presumed to be related to service, and are not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2013). 5. A gastrointestinal disorder, to include GERD and dyspepsia, was not incurred in or aggravated by service and is not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veteran's Claims Assistance Act (VCAA) describes VA's duties to notify and assist claimants in substantiating a 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). The notice requirements were met in this case by letters dated in July 2005, March 2007, and January 2008. The letters notified the Veteran of the information and evidence needed to substantiate and complete claims for service connection, to include notice of what part of that evidence he should provide, and what part VA will attempt to obtain. VA provided notice of how disability ratings and effective dates are determined in the March 2007 and January 2008 letters. The claims were readjudicated by the AOJ most recently in an April 2012 Supplemental Statement of the Case (SSOC). Accordingly, the duty to notify has been satisfied. Regarding the duty to assist, VA has done everything reasonably possible to assist the Veteran with respect to his claims for benefits in accordance with 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c). The Veteran's service treatment and personnel records have been associated with the claims file. In the November 2010 remand, the Board directed the AOJ to request his service records from the National Personnel Records Center (NPRC) and the Chief Bureau of Medicine and Surgery, as well as any in-patient treatment records from Balboa Naval Hospital dated from August 1974 to December 1975. An April 2011 memorandum to the claims folder from the AOJ indicates that the Chief Bureau of Medicine and Surgery is no longer the correct custodian of the Veteran's service records, and that all such available records have already been obtained from the NPRC and associated with the claims file in 1976. In June 2011, the AOJ received a response from Balboa Naval Hospital that no records for the Veteran existed at that facility. The Veteran was notified of the AOJ's efforts and its inability to obtain these records in April 2012. He responded later that month, indicating that he had no additional evidence and requesting expedited processing of his claim. Accordingly, further efforts to obtain service records would be futile. See 38 U.S.C.A. § 5103A(a)(2) (VA is not required to provide assistance to a claimant if no reasonable possibility exists that such assistance would aid in substantiating the claim); see also Hayre v. West, 188 F.3d 1327, 1331-1332 (Fed. Cir. 1999) (VA's efforts to obtain Federal records shall continue until the records are obtained or unless it is reasonably certain that such records do not exist or that further efforts to obtain those records would be futile). VA has also assisted the Veteran in obtaining all identified and available post-service evidence. His VA treatment records have been obtained. During the February 2009 Board hearing, he indicated that he received periodic physicals from his employer. Pursuant to the Board's September 2009 remand, the AOJ sent a letter to the Veteran in October 2009 and asked him to identify and complete an authorization form to release information from his employer. He failed to respond and no further action was taken. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (VA's duty to assist is not a one-way street.) VA examinations were conducted in February 2011. In his October 2012 Brief, the Veteran's representative argued that these examinations were inadequate because they were premised on the available service treatment records and failed to address the Veteran's lay statements as to what he experienced in service. As discussed above, the Veteran's available service treatment records have been obtained and there is no indication that any such records are missing. Moreover, contrary to the representative's assertions, the examiner reviewed the claims file, noted and considered the Veteran's self-reported medical history, conducted appropriate clinical examinations, and provided a complete rationale for all opinions expressed. Therefore, the Board finds that the examination reports are adequate to make a determination on the claims. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As the AOJ obtained the Veteran's VA outpatient treatment records, offered assistance in obtaining his medical records from his employer, obtained his service treatment records, requested any in-patient records from Balboa Naval Hospital, and scheduled the Veteran for appropriate VA examinations, the Board finds that the AOJ has substantially complied with the prior remands. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999). The Veteran testified during a Board hearing in February 2009, at which time the undersigned explained the issues on appeal, asked questions focused on the elements necessary to substantiate the claims, and sought to identify any further development that was required. The Veteran has not contended, and the evidence has not otherwise shown, that the undersigned failed to comply with 38 C.F.R. § 3.103(c)(2) or otherwise committed prejudicial error, either by failing to fully explain the issue or by neglecting to suggest the submission of evidence that may have been overlooked. These actions satisfied the duties a Veterans Law Judge or an Acting Veterans Law Judge has to explain fully the issues and to suggest the submission of evidence that may have been overlooked. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010) (holding that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board). In light of the foregoing, the Board finds that VA's duties to notify and assist have been satisfied and, thus, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Legal Criteria Service connection is established where a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498 (1995). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. 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)). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, service connection may be granted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Analysis The Veteran asserts that he has residuals from a right leg fracture he sustained during service. He also alleges that his current bilateral ankle, knee, and hip disabilities are related to his right leg fracture or are otherwise related to service. In addition, he claims that the medications used to treat these conditions have caused gastrointestinal problems. The Veteran's service treatment records are unremarkable for any complaints, treatment, or diagnoses related to the right leg, ankles, knees, hips or stomach. In October 1974, he complained of left tibial tenderness and the possibility of shin splints was noted. In July 1975, it was noted that his chief complaint was a stress fracture of the left shin. In September 1975, it was noted that he had a contusion of the left heel. The report of his December 1975 discharge examination does not note any abnormalities of the lower extremities or gastrointestinal system. The Veteran's service personnel records reflect that he received a general discharge by reason of unsuitability based on inaptitude. His commanding officers described him as belligerent, reluctant, argumentative, slovenly, substandard, insubordinate, absentminded, and inept. Despite substantial efforts, he was not responsive to repeated counseling and close supervision. Therefore, discharge was recommended. After being discharged in December 1975, the Veteran was admitted to a VA hospital with a five-year history of severe and heavy drug use. Physical examination was within normal limits. He underwent a psychological evaluation and was discharged in March 1976 with a diagnosis of non-psychotic organic brain syndrome, secondary to multiple drug abuse. VA outpatient treatment records reflect that the Veteran fractured his right distal fibula while fishing in July 2002. He underwent surgical repair and developed right leg cellulitis. In March 2003, he complained of bilateral knee and right ankle pain. In June 2003, it was noted that his left knee pain was suspected to be caused by a meniscal tear or injury. In December 2003, X-rays of the knees showed mild degenerative changes bilaterally with a possible small loose body in the right knee. Later that month, the Veteran complained of pain in his legs that started in his feet and moved up to his knees and hips. In July 2005, the Veteran filed the instant claim. He indicated that he fractured his right leg in service and later fractured the same leg. He claimed to have knee, hip, and ankle problems secondary to the right leg fracture. During an August 2005 VA examination for other claimed disabilities, including a psychiatric disorder, the Veteran reported that he was discharged under honorable conditions because he was having difficulties with his knees. He stated that after leaving service, he had further medical problems, including a right femur fracture in 2002. He also reported being involved in several accidents while operating heavy equipment during civilian employment as a welder. On mental status examination, the examiner indicated that the Veteran was not a reliable historian. The examiner opined that the Veteran had an anxiety disorder with a somatic focus that might have played a role in his early discharge from military service. On his February 2007 substantive appeal (VA Form 9), the Veteran said he believed his problems were the result of a right leg stress fracture in boot camp and later at Camp Pendleton. He said he was on light duty and had a "no running" profile. During the February 2009 Board hearing, the Veteran testified that he sustained a right leg stress fracture during training at Camp Pendleton. He said he was taken to the medic, was put on bed rest, and had crutches for about a week or ten days. Hearing Transcript (Tr.) at 3. When asked whether the documented July 1975 stress fracture and September 1975 injury to the left heel were the instances he was describing, he said that they were. Hearing Tr. at 3-4. He then said that he fractured his right ankle fishing because he was dragging his left leg around and his right foot got caught in rocks. Hearing Tr. at 4. He clarified that his other joint problems were the result of having to compensate for the left leg. Id. He also said that he had some problems while in "pre-jump school" after he joined the rangers. He said he landed wrong and hurt his ankle and heel when jumping from a tower. Hearing Tr. at 14. An August 2009 VA outpatient treatment note reflects that the Veteran had a two-day history of bilateral lower leg swelling with occasional sharp pain. The assessment was pedal edema, although there was none found on physical examination. In November 2009, he reported chronic pain in the knees and left hip. He said he had old injuries of the lower left extremity from the military and a prior surgery of the right knee. X-rays of the right hip and knee revealed moderate osteoarthritis. X-rays of the left hip and knee showed severe osteoarthritis. During the February 2011 VA examination, the Veteran reported that he injured his right leg when a drill instructor stood on his shoulders. Two days later, he said he jumped from a cliff and had pain in the right leg, which was treated with ice, crutches, and an Ace bandage. He said he worked as a welder/pipe fitter since 1982 and fractured his right ankle while fishing in 2001. He said he had worsening of right leg pain in 1993. As for the left leg, the Veteran reported that he had no complaints from discharge until 1993. He was unsure which heel he injured in service, but said that he had progressive bilateral heel pain since service that worsened in 1993. He also described vague bilateral ankle pain that worsened in 1993. He said he fractured his right ankle while fishing because of his right leg. He also reported bilateral knee pain beginning in 1978 with swelling beginning in the mid-1980s. He said his bilateral hip pain began around 1993. X-rays of the right ankle showed posttraumatic changes of the distal fibula, medial malleolus, and distal syndesmosis; moderate arthritis of the tibiotalar joint, calcaneal spurs, and possible foreign bodies within the heel seen on lateral view only. X-rays of the right tibia and fibula also showed posttraumatic changes of the distal tibia and fibula, which were noted to be probable chronic sequela of trauma to the mid right tibia. The diagnosis was right ankle status post service open reduction internal fixation of the distal tibia/fibula with posttraumatic changes of the distal fibula, medial malleolus and distal syndesmosis, moderate arthritis of the tibiotalar joint, calcaneal spurs, and possible foreign bodies with the heel. X-rays of the left ankle showed minimal osteophytic changes; chronic tiny avulsion medial malleolus; and posterior calcaneal enthesophyte. X-rays of the left tibia and fibula were negative. The diagnoses were left tibia/fibula pain with alleged stress fracture with normal X-ray and diffuse tenderness on examination; and status post contusion of the left heel with posterior calcaneal enthesophytes. X-rays of the knees revealed bilateral tri-compartmental osteoarthritis with small intra-articular loose bodies on the right and probable intra-articular loose bodies on the left. X-rays of the hips revealed bilateral osteoarthritis with ossific bodies along the lateral margin of the right acetabulum, which was noted could be due to trauma, accessory ossicle variance, or osteophytes. The examiner opined that the Veteran's right leg, bilateral ankle, bilateral knee, and bilateral hip disabilities were "less likely than not permanently aggravated or a result of any event and/or condition that occurred and/or expressed in-service and/or within one year of discharge." The examiner opined that the pain the Veteran experienced in his lower extremities was at least as likely as not a result of work as a welder/pipefitter since 1982 and/or the post service fall that resulted in the right ankle fracture and/or the normal aging process. The examiner further opined that none of the claimed conditions were caused by and/or worsened by an already service-connected disability and the his current diffuse musculoskeletal conditions were not altered or worsened by any event and/or condition that occurred during active service. The examiner explained that the Veteran reported diffuse musculoskeletal pains beginning in 1978, over one year after discharge and that his service treatment records were silent as to any problems concerning the right leg. The examiner noted the Veteran's history of hunting and fishing, which involved walking long distances and climbing. The examiner also noted that the Veteran's spine arthritis suggested diffuse arthritic disease rather than joint specific traumatic arthritis. Regarding the Veteran's gastrointestinal problems, the Veteran reported that he was seen for stomach problems by a family physician in 1978. He said he had a worsening of musculoskeletal problems and began taking more Aspirin. He treated the condition with Rolaids/Tums and said that his symptoms improved over time. The diagnosis was dyspepsia. The examiner ultimately opined that the dyspepsia was "less likely as not" permanently aggravated or a result of an event and/or condition that occurred in service or within one year of discharge. The examiner indicated that it was likely the result of antiinflammatory medication, which was started in 1978, and/or alcohol use and was not caused by a service-connected disability. In this case, the preponderance of the evidence reflects that the Veteran's right leg, bilateral knee, bilateral ankle, bilateral hip, and gastrointestinal disabilities did not manifest in service. See 38 C.F.R. § 3.303(a). To the extent his has been diagnosed with arthritis in these joints, the evidence does not reflect that the arthritis was compensably disabling within one year of discharge from active duty. See 38 C.F.R. §§ 3.307, 3.309. Nor does the evidence support a finding that the Veteran sustained a right leg fracture in service as he claims. The Board in this respect has considered the Veteran's statements in support of his claim. See 38 U.S.C.A. § 1154(a) (requiring that VA give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits). However, the Board finds such assertions are not credible because of his inconsistent reports. He initially claimed to have fractured his right leg; however, his service treatment records clearly show that the possible shin splints or stress fracture involved the left leg. When questioned during the hearing about this, he agreed that the left leg stress fracture and left heel contusion were the injuries he had been referencing. For the first time, he alleged that he fractured his right ankle while fishing because he was dragging his left leg. During the February 2011 VA examination, however, he seemed to return to his original story that he injured his right leg during service. The August 2005 VA examiner noted specifically that the Veteran was not a credible historian and that there was a somatoform element to his anxiety disorder. The Board also notes that although he reported being discharged for medical reasons, this is clearly not the case, as his personnel records indicate he was discharged based on unsuitability due to inaptitude. For all the above reasons, the Board finds the Veteran's statements as to an in-service right leg fracture lack credibility and that the contemporaneous medical and personnel records are much more probative. Regarding any continuity of symptomatology since service, the Veteran's statements regarding the onset of his claimed conditions have also been inconsistent. He initially suggested ongoing right leg problems since service, which caused the other claimed joint problems sometime after discharge. During the February 2011 VA examination, he seemed to indicate that his most of his problems began in 1978 and worsened in 1993. To the extent the Veteran has alleged continuity of symptomatology, there is no showing of chronic disease in service or a combination of manifestations sufficient to identify a disease entity and sufficient observation to establish chronicity at the time. See 38 C.F.R. § 3.303(b); Walker, 708 F.3d at 1337. There were no right leg complaints in service. Although possible left leg shin splints/stress fracture and a left heel contusion were noted, there was no ongoing treatment. Furthermore, his physical examination was normal while he was hospitalized at a VA facility in December 1975. This evidence weighs against finding that a chronic disease or its manifestations was shown in service. The most probative evidence indicates the Veteran's right leg/ankle disability was incurred when he fractured his right ankle in July 2002. His other claimed disabilities were not documented until sometime after that. Therefore, the only remaining question is whether there is a nexus between the Veteran's service and any current right leg, bilateral ankle, bilateral knee, bilateral hip, or gastrointestinal disability. See 38 C.F.R. § 3.303(d). In this case, the most probative and competent evidence preponderates against finding a nexus between the Veteran's claimed disabilities and service. In this regard, the Board finds the February 2011 VA examiner's opinions highly probative. As the VA examiner explained the reasons for his conclusions, which was based on a review of the claims file, a clinical evaluation, and consideration of the Veteran's assertions, these opinions are adequate for the adjudication of these claims and are entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Furthermore, there is no competent evidence linking the Veteran's claimed disabilities to service. The Board has considered the Veteran's lay contentions that his disabilities are related to injuries he sustained in service. In the instant case, however, the Board finds that although the Veteran is competent to describe his symptoms both during and after service, as such requires personal knowledge rather than medical expertise, he is not competent to relate right leg, bilateral knee, bilateral ankle, bilateral hip, and gastrointestinal disabilities to service. The Board notes that the Veteran has argued that his bilateral ankle, knee, and hip disabilities are proximately due to or aggravated by his right leg disability; however, in view of the Board's decision denying service connection for a right leg disability, there is no legal basis for awarding service connection on a secondary basis. This is also true for the gastrointestinal disability, which the Veteran alleges is proximately due to or aggravated by the medication he takes to treat his multiple joint problems. Where, as here, service connection for the primary disability has been denied, the Veteran cannot establish entitlement to service connection, pursuant to 38 C.F.R. § 3.310, for a secondary condition. For the foregoing reasons, the Board finds that the preponderance of the evidence is against the claims of entitlement to service connection for residuals of a right leg fracture, a bilateral ankle disability, a bilateral knee disability, a bilateral hip disability, and a gastrointestinal disorder. Therefore, the benefit of the doubt doctrine is not for application, and the claims are denied. See 38 C.F.R. § 3.102. ORDER Entitlement to service connection for residuals of a right leg fracture is denied. Entitlement to service connection for a bilateral ankle disorder, to include as secondary to residuals of a right leg fracture, is denied. Entitlement to service connection for a bilateral knee disorder, to include as secondary to residuals of a right leg fracture, is denied. Entitlement to service connection for a bilateral hip disorder, to include as secondary to residuals of a right leg fracture, is denied. Entitlement to service connection for a gastrointestinal disorder, to include as secondary to service-connected disabilities, is denied. ____________________________________________ Sonnet Gorham Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs