Citation Nr: 1324812 Decision Date: 08/05/13 Archive Date: 08/13/13 DOCKET NO. 07-26 614 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for chest pain, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 2. Entitlement to service connection for high blood pressure, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 3. Entitlement to service connection for rectal pain with taste of blood, black stools, and excessive intestinal noises and gas, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 4. Entitlement to service connection for weight loss, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 5. Entitlement to service connection for hernia, to include weak stomach, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 6. Entitlement to service connection for liver damage, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 7. Entitlement to service connection for fatigue, weakness, and sleepiness, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 8. Entitlement to service connection for blood loss, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 9. Entitlement to service connection for bilateral foot and leg numbness, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 10. Entitlement to service connection for stomach and esophageal pain, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J.M. Seay, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1969 to November 1973. The Veteran died in December 2009. The appellant is his widow. These matters are before the Board of Veterans' Appeals (Board) on appeal from a May 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. In October 2011, the Board remanded the claims for additional development. The case has been returned to the Board for review. In a January 2011 deferred rating decision, VA determined that the appellant's March 2010 claim for service connection for the cause of the Veteran's death was also a claim for substitution of the appellant for claims pending at the time of the Veteran's death. VA determined that the appellant was eligible for substitution in the Veteran's appeal. FINDINGS OF FACT 1. The most probative evidence is against a finding that the Veteran's chest pain was caused or aggravated by the service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 2. The most probative evidence is against a finding that the Veteran's high blood pressure was caused or aggravated by the service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 3. The most probative evidence is against a finding that the Veteran's rectal pain with taste of blood, and excessive intestinal noises and gas, was caused or aggravated by the service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 4. The most probative evidence is against a finding that the Veteran's weight loss was caused or aggravated by the service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 5. The most probative evidence is against a finding that the Veteran's hernia, to include weak stomach, was caused or aggravated by the service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 6. The most probative evidence is against a finding that the Veteran's liver damage was caused or aggravated by the service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 7. The most probative evidence is against a finding that the Veteran's fatigue, weakness, and sleepiness, was caused or aggravated by the service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 8. In resolving the benefit of the doubt in favor of the Veteran, the evidence is in equipoise as to whether the Veteran's blood loss, which manifested in black stools and a diagnosis of anemia, was aggravated by the service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 9. The most probative evidence is against a finding that the Veteran's bilateral foot and leg numbness was caused or aggravated by the service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 10. The most probative evidence is against a finding that the Veteran's stomach and esophageal pain was caused or aggravated by the service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. CONCLUSIONS OF LAW 1. A chronic disability manifested by chest pain was not caused or aggravated by service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 2. High blood pressure was not caused or aggravated by service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 3. A chronic disability manifested by rectal pain with taste of blood, and excessive intestinal noises and gas, was not caused or aggravated by service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 38 U.S.C.A. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 4. A chronic disability manifested by weight loss was not caused or aggravated by service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 5. A hernia, to include weak stomach, was not caused or aggravated by service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 6. A chronic liver disability was not caused or aggravated by service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 7. A chronic disability manifested by fatigue, weakness, and sleepiness was not caused or aggravated by service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 8. A chronic disability manifested by blood loss and black stools, diagnosed as anemia, was aggravated by service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 9. A chronic disability manifested by bilateral foot and leg numbness was not caused or aggravated by service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 10. A chronic disability manifested by stomach and esophageal pain was not caused or aggravated by service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. 38 U.S.C.A. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). An August 2005 letter satisfied the duty to notify provisions. A separate March 2006 letter notified the Veteran of the regulations pertinent to the establishment of an effective date and of the disability rating. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Duty to assist With regard to the duty to assist, the claims file contains the Veteran's service treatment records (STRs), VA medical treatment records, Social Security Administration (SSA) records, and lay statements. The SSA records were obtained in accordance with the Board's October 2011 remand. Stegall v. West, 11 Vet. App. 268 (1998). A VA examination was provided in December 2005 and a VA medical opinion was obtained in December 2011. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The December 2005 VA examiner reviewed the claims file, examined the Veteran, noted the pertinent evidence, acknowledged the side effects of Etodolac, the medication used to treat the Veteran's service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe and provided a negative nexus opinion with supporting rationale. While the Board finds that the examiner's opinion is adequate with respect to whether the claimed disabilities were caused by the service-connected disability, the December 2005 examiner did not provide an opinion as to whether the claimed disabilities were aggravated by the service-connected disability. Therefore, the Board remanded the case to obtain a medical opinion regarding aggravation. The December 2011 VA physician reviewed the claims file, discussed the pertinent evidence, provided the requested opinion, and discussed the reasoning for the expressed opinion including discussion of the side effects of Etodolac. Therefore, the Board finds the opinion is adequate and the remand directives were completed. See Stegall, 11 Vet. App. 268 (1998). The Board notes that a VA medical opinion was obtained in December 2010 to determine whether the Veteran's service-connected degenerative joint disease of the right great toe caused or contributed to his death. While the opinion was obtained in connection with a claim for service connection for the cause of the Veteran's death, the examination report included a thorough discussion regarding whether the Veteran's liver disease was caused by the medication, Etodolac. This is pertinent to the issue of service connection for liver damage, which is currently before the Board. The opinion is adequate in that the physician reviewed the claims file, provided a full discussion of the pertinent evidence and the side effects of Etodolac, and included reasoning as to why Etodolac did not cause the Veteran's liver disease. See Barr, 21 Vet. App. 303, 312 (2007). Finally, the Board recognizes that there is no medical opinion as to whether the claimed disabilities are causally or etiologically related to active service. However, there is no indication or contention in the record that any of the claimed disabilities are related to the Veteran's active service. Therefore, a VA opinion as to direct service connection is unnecessary. 38 C.F.R. § 3.159(c)(4). The Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist. Legal criteria Service connection - in general Service connection is warranted if it is shown that a Veteran has a disability resulting from an injury incurred, or a disease contracted, in active service or for aggravation of a pre-existing injury or disease in active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). Analysis The Board has reviewed all of the evidence in the claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. The Veteran requested service connection on a secondary basis for the claimed disabilities. The record does not contain any assertion with respect to direct service connection. Therefore, the Board will adjudicate the claims solely on the basis of secondary service connection. The Veteran averred that he experienced chest pain, high blood pressure, rectal pain with taste of blood, black stools, excessive intestinal noises and gas, weight loss, hernia, to include weak stomach, liver damage, fatigue, weakness, sleepiness, blood loss, bilateral foot and leg numbness, and stomach and esophageal pain, related to the use of the medication Etodolac for his service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. In a May 2005 statement, the Veteran explained that since taking Etodolac, his insides ached, he was tired, and lost blood with the taste of blood in his mouth. He stated that his legs went numb, he had high blood pressure, intestine noises and gas, weight loss, and hernias. He said that he experienced severe stomach and chest pain. VA treatment records show that Etodolac was prescribed for the Veteran's service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. The Veteran was prescribed Etodolac from August 2003 to August 2004 and from August 2004 to August 2005. Medical records dated in 2003 reveal diagnoses of borderline hypertension. A September 2003 VA treatment record noted an assessment of chest pain with an abnormal baseline EKG study and the past suggestive of old posterior myocardial infarction. The VA treatment records show complaints of chest/stomach pain, numbness and swelling of extremities, blood loss (resulting in a diagnosis of anemia), fatigue, weakness, and sleepiness. The records also reveal that the Veteran reported experiencing a hernia after lifting a patient in 2004 and he lost weight as instructed by VA physicians in 2005 and 2008. The Veteran submitted a number of articles wherein the side effects of Etodolac were listed. The side effects included: feeling sleepy, inability to think clearly, belly pain, heartburn, cramps, diarrhea, gas, and stomach bleeding or ulceration. It was advised that a healthcare provider be called immediately if there were signs of a life-threatening reaction to include wheezing, tightness in the chest, fever, itching, severe nausea, vomiting, and/or diarrhea, blood in the stool and toilet bowl, unusual bruising or bleeding, and any rash. The Veteran submitted another article which indicated that Etodolac can rarely cause liver disease-possibly fatal liver disease. The article indicated possible side effects of: upset stomach, diarrhea, gas, nausea, constipation, fatigue, stomach pain, swelling of the hands and feet, sudden or unexplained weight gain, easy bruising/bleeding, unusual/extreme tiredness, severe stomach/abdominal pain, and persistent nausea and vomiting. Another article indicated that the use of nonsteroidal anti-inflammatory drugs (NSAIDS), such as Etodolac, can cause high blood pressure, heart attack, kidney problems, bleeding and ulcers in the stomach, intestine low red blood cells (anemia), and liver problems including liver failure. The Veteran was provided a VA examination in December 2005. The examiner reviewed the claims file. The Veteran reported abdominal pain with a reported onset in February 2005. The Veteran stated that he went to the hospital for hernia repair and was found to have low hematocrit (HCT). An esophagogastroduodenoscopy (EGD) was completed and he was found to have esophageal varices. The Veteran claimed that he had stomach and esophageal pain as part of the process. He stated that he had abdominal pain intermittently which worsened when standing or bending over. The Veteran stated that his chest pain began in 2003. The pain was sharp and located at the mid-sternal area. The cardiac work up was negative. Again, the Veteran had esophageal varices on EGD. The Veteran reported experiencing high blood pressure with a reported onset in 2003. He stated that his high blood pressure began after he started to take Etodolac. The Veteran reported experiencing a painful rectum with a reported date of onset in 2004. He stated that he had a history of hemorrhoids in the past while doing construction. He stated that after developing cirrhosis, he had worsening hemorrhoids and increased rectal pain. The Veteran reported weight loss with a date of onset in 2003. It was noted that the Veteran went from 265 pounds to 240 pounds. He attributed the weight loss to complications from liver dysfunction. The examiner noted that the records showed that the Veteran had been trying to lose weight by dietary changes. The Veteran reported experiencing a hernia in December 2004. The Veteran attributed the hernia to when he attempted to lift a patient and felt a painful, tearing sensation in his abdomen. He attributed this to "weakness" caused by Etodolac. The Veteran reported liver damage with a date of onset in February 2005. He stated that he was evaluated for a hernia operation and was found to have lab abnormalities with low HCT and poor liver function. The Veteran had lower extremity edema, jaundice, and easy bruising during that time. He stated that his easy bruising and jaundice resolved after Etodolac was discontinued. The Veteran continued to experience residual effects of lower extremity edema. The Veteran was found to have esophageal varices with evidence of bleeding. The Veteran had been following with GI since and so far the work up was negative for etiology though a diagnosis of cryptogenic cirrhosis was given. The Veteran reported that his fatigue had its onset in 2003. He stated that he had difficulty staying awake during the day and attributed the fatigue to liver dysfunction. The Veteran stated that he had blood loss beginning in 2005. Again, the EGD showed Grade III varices with stigmata of bleeding. It was noted that there were no further episodes of GI bleed since that time. Finally, the Veteran reported tingling of the lower extremities beginning in 2005. The Veteran stated that he first noticed a sensation of pins and needles at the time when he was developing liver dysfunction. On examination, the Veteran had abdominal pain. The examiner stated that the pain was associated with ventral hernia. On examination of the lower extremities, the Veteran had edema and paresthesia. The blood pressure readings were: 127/33, 133/73, and 130/75. The Veteran weighed 244 pounds. The genitourinary system showed that the Veteran had external hemorrhoids. The June 2005 EGD study revealed Grade III varices in the lower third of the esophagus, medium sized hiatus hernia, diffused congested mucosa in the stomach, a few superficial ulcers in the antrum in the stomach, and portal gastropathy. The December 2005 EGD study revealed Grade II varices in the middle third of the esophagus and lower third of the esophagus. There was mild portal hypertensive gastropathy. The December 2005 examination report revealed a diagnosis of cryptogenic cirrhosis of unknown etiology. The problem associated with the diagnosis was liver damage. The disability impacted the Veteran's occupational activities due to memory loss, decreased concentration, lack of stamina, weakness or fatigue, pain, and lower extremity edema and numbness. The Veteran was diagnosed with esophageal varices due to cryptogenic cirrhosis with a resulting problem of chest pain. The Veteran was diagnosed with essential hypertension, intentional weight loss, ventral hernia due to lifting, iron deficient anemia due to variceal bleed due to cryptogenic cirrhosis, which resulted in blood loss, ventral hernia associated with cryptogenic cirrhosis, which resulted in abdominal pain, pain and parathesia due to edema from cryptogenic cirrhosis; and excoriation with diarrhea, currently resolved, which resulted in rectal pain. The examiner opined that the Veteran's liver dysfunction, esophageal varicies, and associated problems were less likely as not caused by or a result of Etodolac use. The rationale was that the Veteran had a possible diagnosis of non-alcoholic steatohepatitis (NASH) with cryptogenic cirrhosis. The lab studies showed normalized liver function and the imaging showed no liver abnormality. The Veteran had spleenomegaly and esophageal varices which were more consistent with splenic vein thrombosis. The examiner stated that the Veteran may possibly have had a transient insult to the liver which rarely happens with NSAIDS such as Etodolac, but found no evidence that the Veteran had ongoing liver disease which was associated with Etodolac use. Although the etiology of NASH was unknown, it was frequently associated with obesity, type II diabetes mellitus, and hyperlipidemia. A VA medical opinion was obtained in December 2010 to determine whether the Veteran's service-connected degenerative joint disease of the right great toe caused or contributed to his death. While the physician was not asked to opine as to whether the Veteran's liver damage was caused or aggravated by a service-connected disability, the physician indicated that the liver condition was not caused by Etodolac. The physician acknowledged that the use of Etodolac can cause hepatic (liver) side effects and there were rare cases of severe hepatic reactions, including jaundice and fatal fulminant hepatitis, liver necrosis, and hepatic failure, some with fatal outcomes. The Veteran was placed on Etodolac on August 21, 2003, but the liver tests performed on April 22, 2003 clearly indicated that the Veteran had a liver condition prior to that date. Therefore, the physician found that the Veteran's liver dysfunction preceded his prescription for Etodolac and the chronic liver failure could not have been caused by Etodolac. The physician noted that it was important to note that the Veteran's gastroenterologists felt that he had NASH or nonalcoholic steatohepatitis. The cause of nonalcoholic steatohepatitis was unknown, although certain drugs were found to be associated with the condition. The physician noted that the article "Epidemiology, clinical features, and diagnosis of nonalcoholic steatohepatitis" did not mention Etodolac as a possible cause or contributing factor and that Etodolac unlikely played a role as Etodolac generally caused reversible and not progressive changes in liver function tests. If Etodolac did cause complete liver failure (which is very rare), it generally occurred as a very acute, fulminant condition rather than a protracted condition. A VA medical opinion was obtained in December 2011. The examiner listed the pertinent evidence in the record. First, the physician opined that it was at least as likely as not that the Veteran's black stools and blood loss were chronically aggravated by the Veteran's use of Etolodac for his service-connected disability. The examiner noted that the Veteran was on Etodolac from August 2003 to August 2004 and from August 2004 to February 2005. The medication was discontinued due to a finding of pancytopenia. The physician stated that the Veteran had a severe iron deficiency anemia in February 2005, as indicated by the hematologist and supported by typical laboratory findings. Iron deficiency in men was rarely due to an inadequate intake of iron, but was associated with chronic bleeding, generally intestinal. The physician remarked that a gastrointestinal cause of blood loss was strongly suggested by the findings on esophagogastroscopy of "stigmata of bleeding" of esophageal varices in early 2005. Clinical notes also attributed the anemia to prior blood loss. The physician stated that the findings of portal hypertensive gastropathy and duodenopathy as well as ulcerations in the stomach suggested that blood was likely being lost from the stomach and duodenum as well as the esophagus. Such blood loss was well-known to be associated with melena (black stools). However, black stools did not constitute a separate condition from the Veteran's blood loss. The physician noted that the Veteran had a normal corpuscular volume study in mid 2003, which suggested that iron deficiency due to bleeding had not occurred as of that date. He was placed on Etodolac in August 2003 and his anemia appeared in 2005, during which time the Etodolac prescription was active. The physician stated that Etodolac is well-known to be associated with gastrointestinal bleeding. Although the Veteran's gastrointestinal bleeding was not caused by Etodolac, the physician opined that it was highly likely that the Etodolac played a role in the duration and severity of the bleeding. Etodolac usage in the presence of a history of gastrointestinal bleeding was associated with a ten-fold increase in risk for additional bleeding. It was noted that the adverse effects of Etodolac were chronic, though not permanent. The physician explained that the level of aggravation was extremely difficult to establish as the Veteran would almost certainly have had persistent blood loss and anemia regardless of whether Etodolac was prescribed or not. The physician accorded 50 percent of the anemia to the Etodolac and 50 percent to his nonservice-connected liver condition. Next, the VA physician opined that the Veteran's chest pain, high blood pressure, rectal pain with taste of blood, excessive intestinal noises and gas, weight loss, hernia to include weak stomach, liver damage, fatigue, weakness and sleepiness, bilateral foot and leg numbness or stomach and esophageal pain were less likely than not permanently aggravated by the service-connected disability. The physician noted that chest pain with heartburn had been associated with the use of Etodolac; however, there were many other potential causes of chest pain. In order to establish a relationship between the chest pain and Etodolac use, it would be necessary to have detailed information of the time course and severity of those complaints with reference to the period of time of Etodolac use, which is not available. In the absence of this knowledge, an aggravating relationship cannot be established. The physician noted that hypertension had been associated with Etodolac use and an aggravating role is possible. However, a review of a large series of blood pressure readings on the "vital signs" section of the electronic records did not indicate a persistent pattern of elevated blood pressures during the period of time of Etodolac use. The Veteran's rectal pain was attributed to excoriations by the previous examiner and a relationship with Etodolac could not be obtained. Etodolac had been associated with taste perversion but a specific relationship to a taste of blood was not referenced. The reference for excessive intestinal noises and gas was likewise unclear. Etodolac had been associated with flatulence, but a specific adverse effect defined as or construed as excessive intestinal noise and gas could not be located. The Veteran's weight loss was attributed to an intentional cause to lose weight. A relationship to Etodolac was not suggested. With respect to the hernia, the physician explained that there was no known relationship between ventral herniation and Etodolac use. An opinion was previously rendered in the negative as to whether the Veteran's liver damage was caused by his use of Etodolac. It was noted that the previous opinion was negative because the abnormalities of the liver were identified before the use of Etodolac and, therefore, the Etodolac could not have caused the liver condition. The physician stated that Etodolac can nonetheless aggravate a preexisting liver condition; however, it was unlikely in this case because, in general, liver damage related to Etodolac was associated with elevations in the liver function tests - ALT and AST. All AST and ALT tests during the period of time during which the Veteran was on Etodolac were normal. The physician opined that the Etodolac did not aggravate the Veteran's liver condition. With respect to the fatigue and weakness, a medical note dated in July 2006 attributed the fatigue and weakness to his liver condition. The physician stated that given the severity of that condition, that appeared probable. Further, the persistence of the symptoms after discontinuing Etodolac and the lack of documentation in the claims file of a time correlation between Etodolac use and fatigue, weakness, and sleepiness, made an aggravating relationship unlikely. The Veteran's bilateral foot and leg numbness were attributed by the December 2005 VA examiner to leg swelling due to his liver condition. Although Etodolac can cause paresthesias, numbness has not been associated with Etodolac use. The Veteran's stomach pain was attributed by the December 2005 VA examiner to his ventral hernia, which was noted to be plausible. The physician stated that stomach pain in general was highly nonspecific and can occur in an enormous variety of conditions. A review of the claims file did not reveal any findings to suggest a correlation with Etodolac use. In summary, the Veteran's chest pain, high blood pressure, rectal pain with taste of blood, excessive intestinal noises and gas, weight loss, hernia to include weak stomach, liver damage, fatigue, weakness and sleepiness, bilateral foot and leg numbness, and stomach and esophagus pain were less likely as not chronically aggravated by his use of Etodolac for his service-connected disability. Initially, the Board finds that service connection is warranted for blood loss, to include black stools, associated with a diagnosis of anemia With respect to the etiology of the disability, the Board finds that the December 2011 VA physician's opinion is the most probative evidence. The physician reviewed the entire claims file including the side effects associated with the medication Etodolac and opined that it was at least as likely as not that the Veteran's blood loss was chronically aggravated by the use of Etodolac for his service-connected disability. The physician explained that the severe iron deficiency anemia noted in February 2005 was associated with blood loss. Etodolac was associated with gastrointestinal bleeding. The physician explained that the adverse effects of Etodolac were chronic, though not permanent. The level of aggravation was extremely difficult to establish as the Veteran would almost certainly have had persistent blood loss and anemia regardless of whether Etodolac was prescribed or not. The physician accorded 50 percent of the Veteran's anemia to the Etodolac and 50 percent to the nonservice-connected liver condition. In reviewing the VA physician's opinion, the Board acknowledges that the physician expressed some concern as to whether the aggravation was permanent as opposed to chronic. However, the physician provided a favorable medical opinion, discussed that bleeding was a side effect of Etodolac and that such bleeding resulted in the diagnosis of anemia. In resolving any doubt in favor of the Veteran, the Board finds that service connection is warranted for blood loss, which manifested in black stools, and a diagnosis of anemia. 38 U.S.C.A. § 5107(b). However, the Board finds that service connection is not warranted for chest pain, high blood pressure, rectal pain with taste of blood, excessive intestinal noises and gas, weight loss, hernia to include weak stomach, liver damage, fatigue, weakness and sleepiness, bilateral foot and leg numbness, and stomach and esophageal pain. In this respect, the December 2005 VA examiner provided a negative nexus opinion, which the Board finds to be probative. As noted above, the examiner noted the Veteran's complaints, reviewed the evidence, discussed Etodolac, and provided negative nexus opinions. The examiner indicated that the Veteran's symptoms were part of a larger disease process - the Veteran's possible diagnosis of NASH with cryptogenic cirrhosis. With respect to the hernia, the examiner associated the hernia with the Veteran lifting a patient and his cirrhosis - not Etodolac. With respect to rectal pain and hemorrhoids, the examiner noted that the Veteran reported experiencing hemorrhoids during his work in construction and that they became worse after his diagnosis of liver disease. The examiner associated this with excoriation and diarrhea. Excoriation is defined as: ". . . a self-induced skin lesion, inflicted by the fingernails or other physical means." Dorland's Illustrated Medical Dictionary 665, 31st edition (2007). In addition, the December 2011 VA physician provided negative nexus opinions with respect to the claimed disabilities. Again, the Board finds the December 2011 VA physician's opinion to be probative as the physician provided a full rationale for the expressed opinion, discussed the side effects of Etodolac, and reviewed the evidence. Ultimately, the physician concurred with the December 2005 VA examiner's opinion that the liver disease was not caused by the use of Etodolac as there were signs of liver disease prior to the use of Etodolac. The physician found aggravation to be unlikely as liver damage related to Etodolac was generally associated with elevations in liver function tests - ALT and AST. The AST and ALT tests during the period of time during which the Veteran was on Etodolac were normal. The opinions from the December 2005 VA examiner and the December 2011 VA physician are further bolstered by the December 2010 VA physician's opinion that the Veteran's liver disease was not caused by Etodolac use. With respect to the other claimed disabilities, as described in detail above, the physician explained that hernia, rectal pain and taste of blood, intestinal noises and gas, weight loss, and leg numbness were not associated with Etodolac use. In addition, with respect to chest pain, the physician explained that without detailed information regarding the pain during the period of Etodolac use, an aggravating relationship could not be established. With respect to hypertension, the physician noted that the medical evidence did not indicate a persistent pattern of elevated blood pressures during the period of time of Etodolac use. With respect to fatigue, sleepiness, and weakness, the VA physician pointed out that fatigue and weakness were related to the Veteran's liver disease, which had not been related to Etodolac use and that a lack of time correlation between Etodolac use and fatigue, weakness, and sleepiness, made an aggravating relationship unlikely. With respect to leg numbness, the physician noted that the December 2005 VA examiner attributed this symptom to the Veteran's liver disease and that numbness has not been associated with Etodolac use. Finally, with respect to stomach pain, the physician noted the December 2005 VA examiner's plausible opinion that the pain was related to the Veteran's hernia and that a review of the claims file did not reveal any findings to suggest a correlation with Etodolac use. In light of the above, the Board finds that the most probative evidence in the record is against the Veteran's claims for service connection on a secondary basis. The record contains numerous articles submitted by the Veteran regarding the side effects of the medication, Etodolac. The Veteran highlighted the side effects caused by Etodolac and indicated that because the symptoms of fatigue, diarrhea, chest pain, stomach pain, swelling of the feet, high blood pressure, and liver failure were listed as possible side effects of the medication, service connection was warranted. However, the VA examiner and VA physician addressed the side effects of Etodolac and provided negative nexus opinions. In addition, the December 2010 VA physician thoroughly discussed the use of Etodolac and the connection with liver disease and determined that the Veteran's liver disease was not caused by Etodolac. The Board accords more weight to the opinions of the VA examiner and VA physicians as they have medical expertise and knowledge regarding the complex medical question as to whether the use of a medication caused or aggravated a disability. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Board recognizes the Veteran's belief that his chest pain, high blood pressure, rectal pain with taste of blood, excessive intestinal noises and gas, weight loss, hernia to include weak stomach, liver damage, fatigue, weakness and sleepiness, bilateral foot and leg numbness, and stomach and esophagus pain were caused or aggravated by the medication Etodolac. The Veteran's wife also submitted a statement in July 2010. She stated that her husband always believed that the arthritis medicine, Etodolac, might have caused or aggravated his liver condition. She stated that they now knew that NSAIDS such as Etodolac can cause damage. She stated that less than 1 percent of those who take Etodolac are affected but that her husband could have been part of the 1 percent. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, neither the Veteran nor his wife are considered competent to provide an opinion as to whether a prescribed medication caused or aggravated a disability. This is a complex medical question that requires medical training, which neither the Veteran nor his wife have been shown to possess. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). In contrast, the VA examiner and VA physician have medical training and knowledge, reviewed the effects of Etodolac, and determined that Etodolac did not cause or aggravate the Veteran's claimed disabilities. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Finally, the Board recognizes that the Veteran indicated that his liver disease was caused by a combination of the prescribed medications Albuterol, Doxazosin Mesylate, and Etodolac. The VA treatment records show that Doxazosin Mesylate was prescribed for the Veteran's prostate and Albuterol was prescribed for asthma. The January 2005 prescription for Doxazosin Mesylate shows that it is used to treat blood pressure and enlargement of the prostate. Indeed, the medical evidence reveals that the Veteran had an enlarged prostate. The Veteran is service-connected for urolithiasis/bladder urolithiasis/bladder outlet obstruction, status-post cystoscopy, ureteral stenting, and shock-wave lithotripsy; however, this did not include benign enlargement of the prostate. The Veteran is also not service-connected for a disability related to asthma. As these medications were not prescribed for treatment of a service-connected disability, the Board need not address the Veteran's contentions that these medications caused or aggravated his liver disease or other claimed disabilities. See 38 C.F.R. § 3.310. In light of the above, the Board finds that service connection on a secondary basis is not warranted for chest pain, high blood pressure, rectal pain with taste of blood, excessive intestinal noises and gas, weight loss, hernia, to include weak stomach, liver damage, fatigue, weakness, and sleepiness, bilateral foot and leg numbness, and stomach and esophageal pain, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe. The Board has considered the benefit-of-the-doubt doctrine; however, the preponderance of the evidence is against the claims. Therefore, the benefit-of-the-doubt doctrine is not applicable and the claims are denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. at 55-57. ORDER Entitlement to service connection for chest pain, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe, is denied. Entitlement to service connection for high blood pressure, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe, is denied. Entitlement to service connection for rectal pain with taste of blood, excessive intestinal noises and gas, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe, is denied. Entitlement to service connection for weight loss, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe, is denied. Entitlement to service connection for hernia, to include weak stomach, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe, is denied. Entitlement to service connection for liver damage, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe, is denied. Entitlement to service connection for fatigue, weakness, and sleepiness, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe, is denied. Entitlement to service connection for blood loss and black stools, diagnosed as anemia, is granted. Entitlement to service connection for bilateral foot and leg numbness, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe, is denied. Entitlement to service connection for stomach and esophageal pain, claimed as secondary to service-connected degenerative joint disease, metatarsophalangeal joint and interphalangeal joint, right great toe, is denied. ____________________________________________ U.R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs