Citation Nr: 1453511 Decision Date: 12/04/14 Archive Date: 12/10/14 DOCKET NO. 06-17 468 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for low back disability, to include degenerative joint and disc disease of the lumbar spine. 2. Entitlement to service connection for a gastrointestinal disorder, to include gastroenteritis and gastroesophageal reflux disease (GERD). 3. Entitlement to service connection for a respiratory disorder, to include emphysema and chronic obstructive pulmonary disease (COPD). REPRESENTATION Appellant represented by: West Virginia Division of Veterans Affairs WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. Neilson, Counsel INTRODUCTION The Veteran served on active duty for training from July 1972 to January 1973, and on active duty from November 1974 to October 1976. This matter came to the Board of Veterans' Appeals (Board) on appeal from a July 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. The Board notes that service connection for low back disability, a gastrointestinal disability, a neurological disorder/brain injury, and a respiratory condition were initially denied in the July 2005 rating action. The Veteran perfected an appeal as to those issues and in August 2009, the Veteran testified at a Board hearing with respect to the issues. In an October 2009 decision, the Board denied service connection for a neurological disorder and right knee disability; the Veteran's claims of service connection for low back disability, gastrointestinal disability, and a respiratory disorder were remanded for development. Those three matters were again remanded in May 2011, which decision also remanded a claim of service connection for left knee degenerative joint disease (DJD) and a claim for a higher initial rating for service-connected traumatic brain injury (TBI). In October 2012, the Veteran testified at a second Board hearing, which hearing was conducted by a different Veterans Law Judge. During that hearing, he presented testimony with respect to the following issues: entitlement to a higher rating for TBI; entitlement to an earlier effective date for the grant of service connection for TBI; and entitlement to service connection for left knee DJD, low back disability, gastrointestinal disability, and a respiratory disorder. In February 2013, the Board advised the Veteran that because he had presented testimony with respect to the issues of entitlement to service connection for low back disability, gastrointestinal disability, and a respiratory disorder to two different Veterans Law Judges, his appeal of those issues would be assigned to a panel of three Veterans Law Judges and both judges who conducted hearings would participate in making the decision in that appeal. See 38 C.F.R. § 20.707 (2014). He was also offered the opportunity to appear at a Board hearing before the third panel member. In February 2013, the Veteran requested a third hearing. See Arneson v. Shinseki, 24 Vet. App. 379, 386 (2011). In March 2013, the Veterans Law Judge who had conducted the October 2012 hearing issued two separate decisions. In one decision, which was issued by a panel of three Veterans Law Judges, the Veteran's claims of entitlement to service connection for low back disability, gastrointestinal disability, and a respiratory disorder were remanded for the agency of original jurisdiction (AOJ) to schedule the Veteran for a third hearing in connection with those claims. In the second decision, which was signed only by the Veterans Law Judge who had conducted the October 2012 hearing, the Veteran was granted an earlier effective date for his award of service connection for residuals of TBI, and the issues of entitlement to an initial rating in excess of 10 percent for residuals of TBI and to service connection for left knee DJD and a psychiatric disorder, to include posttraumatic stress disorder (PTSD) were remanded. A review of the claims file, to include the Veteran's paperless claims files, indicates that the AOJ is still in the process of carrying out the Board's remand directives with respect to the issues of entitlement to service connection for psychiatric disability and left knee DJD, and entitlement to an initial rating in excess of 10 percent for residuals of TBI. Accordingly, those issues are not before the Board for action at this time. On January 30, 2014, the Veteran testified before an Acting Veterans Law Judge, sitting at the RO. Transcripts of all three hearings have been associated with the record. FINDINGS OF FACT 1. The Veteran did not injure his lower back in service; a low back disability was not manifest to a compensable degree within a year of the Veteran's military service and is not otherwise related to his military service. 2. The Veteran does not have a gastrointestinal disorder that is attributable to active military service. CONCLUSIONS OF LAW 1. The Veteran does not have low back disability that is the result of disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2014). 2. The Veteran does not have a gastrointestinal disorder that is the result of disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.303, 3.304 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2014), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2014), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim. They also require VA to notify the claimant and the claimant's representative of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b). As part of the notice, VA is to specifically inform the claimant and the claimant's representative of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The VCAA notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran has not disputed the contents of the VCAA notice in this case. Further, the Board finds that the Veteran was adequately informed of the information and evidence necessary to substantiate the matters decided herein, as well as of VA's duty to assist and of his responsibilities in the adjudication of his claims, via letters dated in April 2005 and January 2008. The Board finds that these letters comply with the requirements of 38 U.S.C.A. § 5103(a) and Dingess, supra, and afforded the Veteran a meaningful opportunity to participate in the development of his claims. Thus, the Board finds that the duty-to-notify requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) were satisfied. Regarding the duty to assist, the Board also finds that VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate the matters decided herein. The evidence obtained or associated with the claims folder includes the Veteran's service treatment records (STRs), service personnel records, VA treatment records, VA examination reports, private medical evidence, records from the Social Security Administration (SSA), and lay statements, to include the Veteran's testimony at three Board hearings. The Board has reviewed the STRs, and finds that they appear complete. The Board also finds that the medical evidence of record is adequate for the Board to rely upon in this case. The Veteran has been afforded VA examinations in connection with the matters decided herein. A review of the examination reports show that the VA examiners reviewed the claims folders and/or pertinent evidence, conducted a thorough examination of the Veteran, and considered the Veteran's subjective complaints related to his disabilities, as well the Veteran's specific theories of service connection. The Board finds that the examination reports, along with the medical and lay evidence of record, contains sufficient evidence by which to evaluate the Veteran's claim decided herein and that the requested opinions can be relied upon in this case. Further, as will be discussed in greater detail below, the Board does not find that the lack of a more detailed rationale renders any opinion inadequate. The Board thus concludes that the Veteran was provided with adequate medical examinations and opinions and that the evidence developed on remand also complies with the terms of the Board's prior remand. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (describing adequacy of medical examinations); Stegall v. West, 11 Vet. App. 268 (1998). II. Analysis The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2014). In addition, certain chronic diseases, including arthritis, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.307, 3.309 (2014). 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). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). Alternatively, for chronic diseases, as defined by regulation, shown in service, the second and third elements of service connection may be established through demonstrating chronicity or continuity of symptomatology in accordance with 38 C.F.R. § 3.303(b). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (38 C.F.R. § 3.303(b) only applies to the listed chronic disabilities in 38 C.F.R. § 3.309(a)). Chronicity is established if the claimant can demonstrate (1) the existence of a chronic disease in service and (2) current or present manifestations of the same disease. Id. Continuity of symptomatology may be established if it is demonstrated that (1) a condition was "noted" during service; (2) there is post-service evidence of the same symptomatology; and (3) there is medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Id. A. Low Back Disability The Veteran seeks service connection for low back disability, which he alleges is related to service. During his August 2009 hearing, the Veteran reported that his regular service-duties included sling-loading helicopter cargo, which duties regularly exposed him to high-voltage static electricity shocks due to improper grounding procedures. He reported being thrown routinely at least 25 feet on account of such shocks. He also testified that he injured his back while stationed at Camp Lejeune when a concrete block hit him in the back while he was loading helicopter cargo. A review of the record shows that in filing his December 2004 application for VA disability benefits for "back problems," the Veteran indicated the date of onset of such problems to have been in 1973. At the time that he first presented to a VA medical facility in August 2003, he had no musculoskeletal complaints. In October 2004, the Veteran presented with complaints of diarrhea and back pain, as well as of upper abdominal pain. The assessment was resolving gastroenteritis and low back pain. In July 2005, the Veteran sought treatment related to low back pain, which he reported had been present for greater than three months. The Veteran was afforded a VA orthopedic examination in February 2010. At that time, he complained of low back pain, which he stated began in 1974. He reported that he injured his back in service when he was setting up a concrete block at Camp Lejeune and it slipped, hitting his lower back. He stated that he had had low back pain on and off throughout the remainder of his service and was informed of degenerative changes in his back around 2003. The examiner noted that past imaging studies demonstrated degenerative changes of the lumbar spine, as well as spinal stenosis and neural foraminal narrowing at the L5-S1 level. Regarding the etiology of the Veteran's diagnosed degenerative joint and disc disease of the lumbar spine, the examiner opined that it was less likely than not that the Veteran's disability was related to his period of military service. The examiner considered the Veteran's assertion that he was hit with a concrete block in service and had had low back pain intermittently since that time. The examiner noted, however, that when the Veteran first presented for post-service treatment at a VA medical center in 2003, he did not complain of past or present back pain. The examiner found no evidence of complaints of back pain until 2004, when the Veteran presented for treatment related to diarrhea. The examiner then stated that the absence of back pain for three decades following service rendered it highly unlikely that the alleged incident in service had any etiological relationship to the Veteran's current degenerative changes of the lumbar spine. In August 2012, the examiner again reviewed the claims folder and provided an addendum opinion wherein he indicated that no evidence associated with the record since he examined the Veteran in 2010 would cause him to change his previously provided opinion. The Veteran again testified at Board hearings in October 2012 and January 2014. During the October 2012 hearing, he reiterated that he had hurt his back in service when he was hit with a concrete block. He reported that he was seen in sick call for his back while in service and stated that he did not file a claim for VA disability benefits for his back disability sooner because he was unaware that he could file such a claim. During the January 2014 hearing, he again reported having injured his back in service, stating that he was hospitalized for a day and placed on light duty for five days. The Veteran denied seeking post-service treatment prior to 2004. Upon review of the evidence, the Board finds reason to question the Veteran's credibility in reporting his alleged in-service injury to his back. In this regard, the Board notes that the Veteran has consistently asserted that he hurt his back while stationed at Camp Lejeune. In claiming service connection for back disability, the Veteran reported that his disability began in 1973; to the VA examiner, however, the Veteran reported that the injury occurred in 1974. Notably, a review of the Veteran's service personnel records show that he first reported for basic recruit training to Parris Island, South Carolina, in July 1972. He was released from his initial training period in January 1973 and served on inactive duty from January 10, 1973, to November 29, 1974, after which time he was to report for active duty at Camp Lejeune. The Veteran's service personnel records note, however, that the Veteran did not report to Camp Lejeune on November 30, 1974, and was absent without leave (AWOL) until January 6, 1975. Accordingly, the Veteran's service personnel records do not place him at Camp Lejeune in either 1973 or 1974. Further, the Veteran's STRs do not substantiate his report of having presented to sick call after sustaining the alleged back injury, nor is there any evidence of him having been placed on light duty for five days as a result of having injured his back. Indeed, the Veteran's STRs are silent for any low back complaints. Although the Veteran testified during his 2009 hearing that he did not otherwise seek treatment for his back in service because any injury from static electricity shocks was just an incident of his service, the Veteran's STRs do demonstrate that he sought frequent treatment related to other orthopedic and musculoskeletal complaints. The Board questions why the Veteran would not mention back pain at the time that he was seeking treatment for knee and/or head pain. Furthermore, in an April 2006 statement submitted in connection with a claim for SSA disability benefits, the Veteran reported that a concrete block hit him in the back and knocked him out while in service at Camp Lejeune and stated that that was not the only time that that happened. The Veteran went on to report: "They never any sort of medical treatment for that sort of thing-it was part of the job. Going to sick bay for that was futile." This statement is seemingly inconsistent with the Veteran's earlier report that he did seek medical treatment after the alleged incident and was in fact in the hospital for a day following the incident. The Board is mindful that it "cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence." Buchanan v. Nicholson, 451 F.3d 1331, 1334-37 (Fed. Cir. 2006). The Board finds, however, the inconsistencies in the Veteran's report, to include that he was not stationed at Camp Lejeune at the time he alleged the injury to his back to have occurred, along with the lack of any in-service evidence documenting, or even suggesting, a back injury during that time, to include being placed on light duty, make him an incredible historian as to all assertions of an in-service back injury. See Buchanan, 451 F.3d at 1337 ("[T]he Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc."); Caluza v. Brown, 7 Vet. App. 498, 511 (1995) ("The credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character."), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). In sum, the Board finds there to be no evidence, other than the Veteran's own statements, which the Board has deemed not credible, that he sustained back injury in service. Without evidence of in-service incurrence or aggravation of a disease or injury, a finding of service connection for low back disability cannot be made. See Davidson, supra. Moreover, the evidence does not otherwise establish a nexus between the Veteran's current back disability and service. Further, because the evidence fails to demonstrate the existence of a chronic disease in service or that a chronic disease was "noted" during service, service connection is also not warranted by virtue of application of 38 C.F.R. § 3.303(b). Nor can it be said that arthritis manifested to a compensable degree within a year of separation from service, as there is no evidence suggestive of arthritis dated within a year of service and the Veteran himself reports that he was not informed of degenerative changes in his back until approximate 2003. Accordingly, because the evidence also fails to establish the in-service incurrence of low back disability, there is simply no basis upon which a finding of service connection can be made for such, as two crucial elements of service connection have not been shown. See Davidson, supra (service connection requires evidence of in-service incurrence or aggravation of a disease or injury and a nexus between the claimed in-service disease or injury and the present disability). Further, although the Veteran believes that he has a low back disability that is due to service, the Board notes that etiology of dysfunctions and disorders is generally a medical determination. See Jandreau v. Nicholson, 492 F.3d 1372, 1374-75 (Fed. Cir. 2007); see also 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). Here, the Veteran, as a lay person without the appropriate medical training and expertise, is not competent to make such an etiological conclusion, especially in light of the fact that the Veteran's allegation of an in-service injury has been deemed not credible and the evidence fails to demonstrate the onset of low back disability in service. See Jandreau, supra. The Board has considered the benefit-of-the-doubt doctrine, but finds that the record does not provide even an approximate balance of negative and positive evidence on the merits. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 C.F.R. § 3.102 (2013). Therefore, on the basis of the above analysis, and after consideration of all the evidence, the Board finds that the preponderance of the evidence is against the claim for service connection for low back disability. B. Gastrointestinal Disorder The Veteran seeks service connection for a gastrointestinal disorder, which he alleges is related to service. In filing his December 2004 application for VA disability benefits for such, the Veteran reported that he began having stomach problems in 1997. A review of the claims folders shows that the Veteran first presented to a VA medical facility in August 2003, at which time he sought treatment for groin pain. He had no gastrointestinal complaints at that time and was noted to have bilateral inguinal hernias. The following month, he presented with complaints of pain related to his hernias, describing the pain as intermittent and intense, lasting for less than three months. He underwent an inguinal herniorrhaphy that same month. In October 2004, the Veteran presented with complaints of diarrhea and back pain, as well as of upper abdominal pain. The assessment was resolving gastroenteritis and low back pain. He again presented with complaints of abdominal pain in December 2004, which he then indicated had persisted for more than three months. In a May 2005 statement, the Veteran indicated his belief that his stomach problems were due to "inhaling broken glass while sling-loading old cars for target practice while in Puerto Rico." In a June 2007 statement, the Veteran alleged that his stomach and digestive problems were potentially related to drinking contaminated water at Camp Lejeune in North Carolina, where he was stationed during service. During his August 2007 hearing, the Veteran again reported that while stationed at Camp Lejeune, he drank tap water. Regarding his claimed gastrointestinal disorder, the Veteran reported having a sore stomach, which has "been like that ever since [he] got out of service." The Veteran was afforded a VA examination in connection with his claim in February 2010. At that time, he complained of soreness in the epigastric region, which he stated began in 1974. The Veteran stated his belief that his epigastric discomfort was the result of drinking contaminated water at Camp Lejeune. Upon examination of the Veteran and a review of the claims folder, to include the reports of all previously performed gastroenterology procedures, the examiner diagnosed GERD, gastritis, and duodenitis, with associated soreness in the epigastric region, as evidenced by the results of three endoscopies performed in October 2007, July 2008, and August 2009. The examiner further indicated that a biopsy of the esophagus in August 2009 revealed mild chronic inflammation of the distal esophagus, consistent with reflux esophagitis. The examiner's findings are consistent with the procedure reports contained in the Veteran's VA treatment records. Regarding the Veteran's theory of causation, the examiner noted that a National Academy of Sciences report on the potential health effects of contaminated water supplies at Camp Lejeune from 1957 to 1985 concluded that there were elevated levels of industrial solvents in the water during those years. The examiner acknowledged that the Veteran would have been exposed to those solvents, but explained that although there was limited evidence of an association between the indicated industrial solvents and a variety of diseases, most of which were cancers, there was no evidence of any association between the indicated industrial solvents and gastritis, duodenitis, GERD, or hiatal hernias. The examiner thus concluded that the Veteran did not have a gastrointestinal disorder etiologically related to his military service. In August 2012, the examiner again reviewed the claims folder and provided an addendum opinion where he indicated that no evidence associated with the record since he examined the Veteran in 2010 would cause him to change his previously provided opinion. The Veteran again testified at Board hearings in October 2012 and January 2014. During the October 2012 hearing, he reported first having stomach problems in service. During the January 2014 hearing, he again asserted his belief that his gastrointestinal symptoms were related to drinking contaminated water at Camp Lejeune. At the outset, the Board notes that the Veteran's service personnel records establish that he was stationed at Camp Lejeune during service. The Board further notes that VA has acknowledged that persons residing or working at the U.S. Marine Corps Base Camp Lejeune from August 1953 through December 1987 were potentially exposed to drinking water contaminated with volatile organic compounds (VOCs) and it will be assumed by VA that any given Veteran-claimant who served at Camp Lejeune was potentially exposed in some manner to the full range of chemicals known to have contaminated the water there between 1957 and 1987. See Veterans Benefits Administration (VBA) Fast Letter 11-03 (January 11, 2011); VBA Training Letter 11-03 (Revised) (November 29, 2011). In 2009, the National Academy of Sciences' National Research Council (NRC) published a report of its study assessing the potential long-term health effects for individuals who served at Camp Lejeune during the period of water contamination, entitled Contaminated Water Supplies at Camp Lejeune, Assessing Potential Health Effects. This report included a review of studies addressing exposure to trichloroethylene (TCE), a metal degreaser, and perchloroethylene (PCE), a dry cleaning agent, as well as a mixture of the two, and disease manifestations potentially associated with such exposure. Fourteen disease conditions were identified as having limited/suggestive evidence of an association with TCE, PCE, or a solvent mixture exposure. See VBA Training Letter 11-03 (Revised) (November 29, 2011), Appendix B (listing esophageal cancer, lung cancer, breast cancer, bladder cancer, kidney cancer, adult leukemia, multiple myeloma, myleodisplasic syndromes, renal toxicity, hepatic steatosis, female infertility, miscarriage with exposure during pregnancy, scleroderma, and neurobehavioral effects as the 14 diseases). As noted above, the VA examiner considered the Veteran's specific theory of causation, but upon review of the National Academy of Sciences' report, determined that there was no evidence to support an association between any diagnosed gastrointestinal disorder and his presumed exposure to certain chemicals through the drinking of contaminated water at Camp Lejeune. The Board finds no reason to reject the examiner's opinion in this regard, as there is no indication from the NRC's report that any gastrointestinal disorder has been associated with drinking contaminated water at Camp Lejeune. See id. Moreover, the evidence does not otherwise suggest an association between any diagnosed gastrointestinal disorder and service. In this regard, the Board notes that the VA examiner's rationale for his ultimate opinion that the Veteran's diagnosed GERD, gastritis, and/or duodenitis is not etiologically related to the Veteran's military service is seemingly limited to why a gastrointestinal disorder is not related to drinking contaminated water at Camp Lejeune. There is, however, no requirement imposed on a medical examiner to provide detailed reasons for an opinion. See Ardison v. Brown, 6 Vet. App. 405, 407 (1994). Rather, an examiner is required only to consider all of the relevant evidence before forming an opinion and support his or her opinion with an analysis that the Board can consider and weigh against contrary opinions. Stefl, supra. In the instant case, there is no indication that the VA examiner failed to consider any piece of relevant evidence before opining against an etiological association between the Veteran's GERD, gastritis, and/or duodenitis and service. Further, the examination request was in no way limited to asking the examiner to consider only whether the Veteran had a gastrointestinal disorder related to drinking contaminated water at Camp Lejeune. Thus, the Board will presume that the examiner reviewed the claims folder in its entirety and considered whether there was any evidence to support an etiological association between a diagnosed gastrointestinal disorder and service in general. Thus, although not supported by an overly detailed rationale, the Board also finds no reason to discount the examiner's ultimate medical opinion based on the clinician's expertise and qualifications as a medical professional. Moreover, no other medical professional has specifically attributed any diagnosed gastrointestinal disorder to service. Thus, given the absence of contrary medical evidence in this case, the Board need not weigh the VA examiner's negative nexus opinion against other medical evidence. Indeed, there is no evidence, other than the Veteran's own assertions, to suggest that he has a gastrointestinal disorder that is attributable to service. Although the Veteran believes that he has a gastrointestinal disorder that is attributable to service, as noted above, the etiology of dysfunctions and disorders is generally a medical determination. See Colantonio and Jandreau, both supra. Here, the Veteran, as a lay person without the appropriate medical training and expertise, is not competent to make such an etiological conclusion, especially in light of the VA examiner's conclusion to the contrary and the Veteran's history of inguinal hernias with associated complaints of abdominal pain. Further, in finding that service connection for a gastrointestinal disorder is not warranted based on the lack of nexus evidence, the Board is cognizant of the fact that "[l]ay testimony is competent . . . to establish the presence of observable symptomatology and 'may provide sufficient support for a claim of service connection.'" See Barr, supra (quoting Layno v. Brown, 6 Vet. App. 465, 469 (1994)). Notably, however, because none of the Veteran's diagnosed gastrointestinal disorders is one of the conditions identified in 38 C.F.R. § 3.309(a), the recent holding in Walker, supra, would indicate that the nexus prong cannot be established by demonstrating chronicity or continuity of symptomatology in accordance with 38 C.F.R. § 3.303(b). Further, although the Veteran later testified that he has experienced epigastric pain and gastrointestinal symptoms since service, in first claiming service connection for a gastrointestinal disorder, the Veteran indicated its onset to have been in 1997. Moreover, the Veteran's STRs are silent for gastrointestinal complaints and in presenting for complaints of groin pain in 2003, the Veteran had no gastrointestinal complaints. In light of this evidence, the Board finds the lay evidence of record regarding the onset and continuity of gastrointestinal symptoms is not credible. In sum, because there is no probative evidence attributing a diagnosed gastrointestinal disorder to service, the Veteran's claim of service connection for such must be denied. See Davidson, supra. In finding that service connection for a gastrointestinal disorder is not warranted based on the lack of nexus evidence, the Board has considered the benefit-of-the-doubt doctrine, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The Board is unable to identify a basis for granting service connection in this case. See 38 U.S.C.A. § 5107(b) (West 2002); Gilbert, supra; 38 C.F.R. § 3.102. ORDER Service connection for low back disability is denied. Service connection for gastrointestinal disability is denied. REMAND Regarding the Veteran's claim of service connection for a respiratory disorder, the Veteran has stated his belief that he has a respiratory disorder as result of asbestos exposure in service. The Veteran has reported that while he was stationed aboard the USS Nashville, the ship was involved in an accident whereby it was hit by another ship that "tore a big hole in the port side of the [USS Nashville]" and caused numerous pipes to burst. The Veteran alleged having been exposed to asbestos as a result of this accident and reported that the ship underwent repairs in Spain. At the outset, the Board notes that the Veteran has been inconsistent with his reporting of when the alleged incident aboard the USS Nashville occurred. Further, his service personnel records do not provide exact documentation of his dates of service aboard the USS Nashville. Nevertheless, the Veteran's DD Form 214 reflects that he had six months of foreign and/or sea service, his service personnel records show that he had a temporary assigned duty (TAD) period from February 1975 to September 1975, and his STRs show that the was treated aboard the USS Nashville in March, May, June, and July 1975. Further, internet research shows that the USS Iwo Jima and the USS Nashville were involved in a collision in March 1975 and that the USS Nashville was deployed in the Mediterranean from March 1975 to August 1975. See http://www.damagecontrolmuseums.org/Ship_Cas_history/cas_index.html; http://www.hullnumber.com/LPD-13. Moreover, a VA examiner who examined the Veteran in February 2010 explained that steam pipes were generally insulated with asbestos in the 1970s, and surmised that the Veteran very well could have inhaled asbestos fibers in service. Thus, there appears to be at least some support for the Veteran's assertion that he was in fact exposed to asbestos in service. Regarding the likelihood that the Veteran has a respiratory disorder related to service, to include his alleged asbestos exposure, the February 2010 VA examiner opined that it was less likely than not that the Veteran's diagnosed COPD was related to service. The examiner stated that although the Veteran could have been exposed to asbestos in service, there was no evidence that the Veteran developed an asbestos-related disease from any in-service exposure to asbestos fibers. The examiner explained that asbestosis does not produce obstructive lung disease, but rather, produces restrictive lung disease with interstitial fibrosis and reduced lung volumes. The examiner indicated that although there was evidence of some reduced diffusion capacity, that was more likely than not a manifestation of the Veteran's chronic COPD, which produced some thickening of the alveolar walls. The examiner then attributed the Veteran's COPD to his history of heavy tobacco use. Due to the inclusion of additional medical evidence in the record, the examiner again reviewed the claims folder in August 2012 and provided an addendum opinion wherein he indicated that no evidence associated with the record since he examined the Veteran in 2010 would cause him to change his previously provided opinion. Notably, although it appears that pulmonary function testing was undertaken as part of the Veteran's 2010 VA examination, the two imaging studies relied upon by the examiner were from 2006 and 2009. There is no indication, however, that the examiner reviewed or considered the findings demonstrated by other imaging studies of record. A review of the Veteran's VA treatment records contained in both his paper and paperless claims folders reveals that a February 2005 chest x-rays was interpreted to show "diffuse interstitial disease," that a December 2008 chest x-ray demonstrated "chronic interstitial changes," that a February 2009 chest x-ray evidenced nonspecific interstitial changes, and that a February 2009 computed tomography (CT) scan of the chest showed increased ground-glass opacity and peripheral interstitial markings. The Veteran's computerized problem list also includes "chronic interstitial lung disease." Given the evidence suggestive of some type of interstitial lung disease, and in light of the VA examiner's explanation that asbestosis produces restrictive lung disease with interstitial fibrosis, the Board finds that the matter must again be remanded for the Veteran to be afforded a new VA examination that includes current imaging studies and an opinion that takes into account all relevant evidence, to include that suggestive of interstitial lung disease. See Stefl, 21 Vet. App. at 124 (holding that it is incumbent on the VA examiner to consider all of the relevant evidence before forming an opinion); see also VBA Adjudication Procedure Manual M21-1 Manual Rewrite (M21-1MR), Part IV, Subpart ii, Ch.2 Section C, Topic 9 (Dec. 13, 2005) and Section H, Topic 29 (Sep. 29, 2006) (providing that asbestos-related diseases/abnormalities include interstitial pulmonary fibrosis, tumors, effusions and fibrosis). Accordingly, the case is REMANDED to the AOJ for the following action: 1. The AOJ must verify the Veteran's dates of service aboard the USS Nashville. All attempts to obtain this data, and any responses received, should be documented in the claims folder. 2. The AOJ must attempt to verify the Veteran's allegation that the USS Nashville was involved in a collision with another ship resulting in a hole in the hull of the USS Nashville. Such development should include obtaining the ships logs from the USS Nashville (LPD-13) for March 1975, as internet research tends to suggest that a collision with the USS Iwo Jima occurred that month. If the ships logs from March 1975 do not confirm the alleged incident, attempts to verify whether the incident occurred at any point during the time that the Veteran was stationed aboard the USS Nashville should be undertaken. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's respiratory disorder. The claims folder, and a copy of this remand, must be provided to and reviewed by the examiner as part of the examination. All necessary tests and studies should be conducted to determine whether the Veteran has an asbestos-related disease or abnormality. If it is determined that the Veteran does not have an asbestos-related disease, the examiner should specifically address the significance of the following evidence: a February 2005 chest x-ray showing "diffuse interstitial disease"; a December 2008 chest x-ray demonstrating "chronic interstitial changes"; a February 2009 chest x-ray evidencing nonspecific interstitial changes; and a February 2009 chest CT showing increased ground-glass opacity and peripheral interstitial markings. The examiner should also discuss the nature of the Veteran's "chronic interstitial lung disease" listed on his computerized problem list. The examiner should then opine as to whether it is at least as likely as not that any current respiratory disorder had its onset during the Veteran's active duty or is otherwise causally or etiologically related to his active service or any incident therein, to include his alleged exposure to asbestos. 4. After undertaking any other development deemed appropriate, the AOJ should re-adjudicate the issue of entitlement to service connection a respiratory disorder. If the benefit sought is not granted, the Veteran should be furnished with a supplemental statement of the case and afforded an opportunity to respond before the record is returned to the Board for further review. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the Veteran until he is notified. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for (CONTINUED ON THE NEXT PAGE) Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2014). MILO H. HAWLEY THOMAS H. O'SHAY Veterans Law Judge Acting Veterans Law Judge Board of Veterans' Appeals Board of Veterans' Appeals ________________________________ CHERYL L. MASON Veterans Law Judge Board of Veterans' Appeals Department of Veterans Affairs