Citation Nr: 1611192 Decision Date: 03/18/16 Archive Date: 03/23/16 DOCKET NO. 07-12 381 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts THE ISSUE Entitlement to service connection for a gastrointestinal disorder manifested by gastroesophageal reflux disease (GERD) and intestinal blockage, claimed as secondary to service-connected ventral hernia. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Mainelli, Counsel INTRODUCTION The Veteran served on active duty from February 1943 to December 1945. This appeal to the Board of Veterans' Appeals (Board) arose from a July 2006 rating decision by the Boston RO (hereinafter agency of original jurisdiction (AOJ)). In that decision, the AOJ denied a compensable evaluation for appendectomy scar, denied a compensable evaluation for right inguinal hernia, denied service connection claims for diabetes mellitus, constipation/intestinal blockage, pernicious anemia, and shakes and chills; and denied applications to reopen service connection claims for a back condition and a leg condition. In September 2006, the Veteran filed a notice of disagreement (NOD) with respect to the AOJ's denials of compensable ratings for his appendectomy and right inguinal hernia repair scars, and the denials of service connection for diabetes mellitus, intestinal blockage and pernicious anemia. The AOJ issued a statement of the case (SOC) in February 2007, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in April 2007. In May 2009, a Deputy Vice Chairman of the Board granted the motion of the Veteran's representative to advance this appeal on the Board s docket, pursuant to 38 USCA § 7107((a)(2) (West 2002) and 38 C.F.R. § 20.900(c) (2008). In June 2009, the Board remanded the claims on appeal to the AOJ for further evidentiary development. At that time, the Board rephrased the service connection claim for "constipation/intestinal blockage" as a service connection claim for a gastrointestinal disorder. A November 2010 AOJ rating decision awarded a 10 percent rating for right inguinal repair and appendectomy scars effective November 20, 2009; as well as granted service connection and assigned an initial 20 percent rating for ventral hernia, effective May 16, 2005. An April 2012 Board decision denied service connection for diabetes mellitus as secondary to service-connected appendectomy scar, denied a compensable rating for appendectomy scar, denied a compensable rating for right inguinal hernia repair scar prior to November 20, 2009, and denied a rating greater than 10 percent for right inguinal hernia repair scar from November 20, 2009. At that time, the Board rephrased the issue on appeal as entitlement to service connection for a gastrointestinal disorder, specifically GERD and intestinal blockage. The Board remanded claims of entitlement to service connection for a gastrointestinal disorder, specifically GERD and intestinal blockage and entitlement to service connection for pernicious anemia, including as secondary to appendectomy scar, to the AOJ for further evidentiary development. A January 2013 Board decision denied service connection claims for a gastrointestinal disorder, specifically GERD and intestinal blockage, and entitlement to service connection for pernicious anemia, including as secondary to appendectomy scar. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). By order dated September 3, 2013, the Court remanded the claim of entitlement to service connection for a gastrointestinal disorder, specifically GERD and intestinal blockage, pursuant to the terms of a Joint Motion for Remand (JMR) filed by representatives for the Veteran and the VA Secretary. The Veteran abandoned his appeal on the issue of entitlement to service connection for pernicious anemia, including as secondary to appendectomy scar. In March 2014, the Board remanded to the issue of entitlement to service connection for a gastrointestinal disorder, specifically GERD and intestinal blockage, claimed as secondary to service-connected ventral hernia, for additional development. After accomplishing the requested actions, the AOJ continued to deny the claim (as reflected in the August 2014 supplemental SOC (SSOC)) and returned this matter to the Board for further appellate consideration. FINDINGS OF FACT 1. All notification and development action needed to fairly the matter herein decided has been accomplished. 2. Competent, probative medical opinion evidence on the question of whether the Veteran's chronic abdominal pain and gastroparesis, to include constipation and GERD, are proximately due to service-connected disability is at least, in relative equipoise. CONCLUSION OF LAW Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for a gastrointestinal disorder manifested by GERD and intestinal blockage, as secondary to service-connected ventral hernia, are met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION At the outset, the Board notes that the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2015). Given the Board's favorable resolution with respect to the claim for service connection for a gastrointestinal disorder manifested by GERD and intestinal blockage secondary to service-connected ventral hernia, the Board finds that all necessary actions in connection with this appeal have been accomplished. The Veteran contends that he is entitled to service connection for his currently manifested gastrointestinal disorders. He primarily asserts that his recurrent symptoms of constipation and epigastric distress are attributable to delayed and protracted surgical treatment for appendicitis during service, which includes adhesions and a ventral hernia. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prevail on the issue of service connection, there must be (1) evidence of a current disability; (2) medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may be presumed, for certain chronic diseases which develop to a compensable degree within a prescribed period after discharge from service, although there is no evidence of such disease during the period of service. This presumption is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Also, while the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree. 38 C.F.R. § 3.307(c). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributed to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is questioned. When the fact of chronicity in service is not adequately supported, then the showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The Federal Circuit has held that the continuity and chronicity provisions of 38 C.F.R. § 3.303(b) only apply to the chronic diseases enumerated in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), overruling Savage v. Gober, 10 Vet. App. 488, 495-96 (1997) (applying 38 C.F.R. § 3.303(b) to a chronic disease not listed in 38 C.F.R. § 3.309(a) as "a substitute way of showing in-service incurrence and medical nexus.") Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires: (1) competent evidence (a medical diagnosis) of current chronic disability; (2) evidence of a service-connected disability; and (3) competent evidence that the current disability was either (a) caused or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet .App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). However, a medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Considering the pertinent evidence in light of the governing legal authority, and resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection for a gastrointestinal disorder manifested by GERD and intestinal blockage, as secondary to service-connected ventral hernia, is warranted. The Veteran's STRs reflect that he underwent right indirect inguinal hernia repair surgery in February 1943. While on the high seas on November 16, 1944, he suffered from acute appendicitis manifested by severe right lower quadrant (RLQ) abdominal pain, chills, fever, constipation, nausea and vomiting. He was transferred to the U.S. Naval Hospital in Chelsea, Massachusetts where, on November 19, 1944, he initially underwent blunt dissection of appendix abscess. On January 13, 1944, the Veteran was transferred to the U.S. Naval Convalescence Hospital (USNCH) in Springfield, Massachusetts to undergo an appendectomy, which was performed on February 21, 1945. He was discharged as fully recovered on April 10, 1945. His December 1945 separation examination, while noting a right herniorraphy scar, otherwise indicated a "NORMAL" clinical evaluation of the abdomen. By means of a rating decision dated January 1946, the AOJ granted service connection for healed, asymptomatic appendectomy scar and assigned an initial noncompensable rating. The AOJ also awarded service connection for operated, cured, right inguinal hernia and assigned an initial noncompensable rating. An October 1979 VA examination report does not reflect any lay or medical evidence of a chronic gastrointestinal disorder. The Veteran originally filed a claim for VA compensation for "digestive problems" in 2001. He theorized that his delayed surgery for appendicitis in service allowed "poison" to circulate throughout his body which caused several "disfunctions [sic] in my digestive system." In an August 2005 statement, the Veteran referred to a history of "intestinal blockages," constipation and stomach problems since service. The accompanying private medical records reflect that, in December 1999, the Veteran was prescribed Citrucel for constipation. In October 2003, he reported symptoms of epigastric pain and constipation. He was assessed as having epigastric pain secondary to gastritis and advised to stop taking aspirin. In June 2004, he reported occasional heartburn which he self-treated with garlic. A July 2004 colonoscopy report was interpreted as showing diverticulosis. The Veteran's private clinic records in 2005 reflected his continued complaints of constipation. In December 2005, he sought emergency room treatment for diffuse abdominal pain. An evaluation, which included abdominal series testing, found no abnormality to explain his abdominal pain. In January 2006, the Veteran was prescribed Prevacid based on an impression of probable hiatal hernia. He was subsequently diagnosed with GERD treated with medications. There is no medical evidence of treatment or diagnosis for "intestinal blockage." On VA examination in June 2006, the Veteran referred to vomiting 1 to 2 times a month at night only if he ate chocolate that day. He otherwise ate, drank, voided and stooled normally. An abdominal series x-ray was interpreted as showing nonspecific bowel gas pattern with a moderate-to-large amount of stool within the colon. The VA examiner provided the following impression: Chronic abdominal pain, most likely secondary to adhesions formed after his initial abscess evacuation in 1944, during Navy service. He attributes this to the epidural performed a few months later, when he had repeat surgery in Springfield. I suspect his pain then as now, was due to adhesions. On VA digestive disorders in November 2009, the Veteran described the onset of bowel dysfunction manifested by constipation with alternating diarrhea in approximately 1997. At the same time, he developed symptoms of abdominal pain relieved by sitting at the edge of his bed and burping, or moving his bowels. He was treating these symptoms with omeprazole. The examiner indicated that the Veteran had diastasis/ventral hernia which was difficult to observe as the Veteran had trouble breathing in supine position. However, when asked to cough, his ventral hernia ballooned out and was readily palpable as the rectus muscles dislodged laterally. The examiner then provided the following opinion: Veteran has scars on abdomen of repaired inguinal hernias and ruptured drainage and appendectomy. In my opinion the [V]eteran's digestive problem is at least as likely as not related to his military service. This opinion is based on the presumption that his abdominal wall musculature was stressed by military service to the same degree that his inguinal hernia. I do not consider the digestive disorder resulting from gastroparesis as a complication of diabetes nor do I consider the digestive problem to be a manifestation of Irritible Bowel Syndrome. The Board observes that, according to the U.S. Department of Health and Human Services, gastroparesis-also called delayed gastric emptying-is a disorder that slows or stops the movement of food from the stomach to the small intestine. http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/gastroparesis/Pages/facts.aspx. The most common symptoms of gastroparesis are nausea, a feeling of fullness after eating only a small amount of food, and vomiting undigested food-sometimes several hours after a meal. Id. Other symptoms of gastroparesis include GERD-a condition in which stomach contents flow back up into the esophagus (the organ that connects the mouth to the stomach), pain in the stomach area, abdominal bloating and lack of appetite. Id. By means of a rating decision dated November 2010, the AOJ granted service connection for ventral hernia effective May 16, 2005. The AOJ assigned an initial 20 percent rating by analogy to Diagnostic Code 7339 (post-operative ventral hernia), which contemplates a small hernia which was not well supported by a belt under ordinary circumstances or healed ventral hernia or post-operative wounds with weakening of abdominal wall and indication for a supporting belt. See 38 C.F.R. § 4.114, Diagnostic Code 7339. In July 2011, a VA examiner examined the Veteran and concluded that it is unlikely that GERD or an episode of apparent bowel obstruction was related to the in-service appendicitis. The examiner explained that the events in question were many years apart and wholly unrelated in his medical opinion. The claims file was not available to the VA examiner for review. In April 2012, the Board remanded the claim remaining on appeal for an addendum medical opinion-one that clarified that the claims file was reviewed and that the Veteran's own account of symptoms dating back to active service was adequately considered. On VA examination in July 2012, the Veteran reported nightly pressure on his chest which was relieved by sitting up and burping. He reported the onset of these symptoms to approximately 10 years prior. The VA physician reviewed the pertinent medical history and concluded that there was no evidence that an intestinal blockage or GERD began during active service. The Veteran had been treated for an episode of gastritis in 2005, and was diagnosed with GERD in 2010. The physician noted that, except for a complaint of constipation during active service, there was no documented gastric or bowel-related issue during active service or for many years thereafter, including during multiple post-service medical examinations. The physician indicated that there could be no medical reason to relate a remote appendectomy scar to any current claimed gastrointestinal issues. The examiner opined that it was less likely than not that the Veteran's gastrointestinal disorders were related to an in-service event or appendicitis or appendectomy scar and, furthermore, was not aggravated by any in-service event, appendicitis or appendectomy scar. Pursuant to the terms of the JMR, the Board remanded this claim in March 2014 for additional opinion as to whether the Veteran's gastrointestinal disorder, claimed as GERD and intestinal blockage, may have been caused and/or aggravated by service-connected ventral hernia. In a May 2014 opinion, the July 2012 VA examiner found upon review of the claims file only that it was less likely than not that the Veteran's gastrointestinal disorder manifested by GERD and intestinal blockage was proximately due to or the result of active service. In so doing, the VA examiner provided the following rationale: 1. FIRST AND FOREMOST, THE DIAGNOSIS OF VENTRAL HERNIA MUST BE CONSIDERED AS THERE IS BUT A SINGLE EXAM WHERE THE "DIAGNOSIS" WAS MADE AND THIS WAS ALSO DIAGNOSED AS POSSIBLY A DIASTASIS. AS THERE ARE INNUMERABLE OTHER EXAMS PRIOR TO AND FOLLOWING THIS EXAM IN 2009 WITH ABSOLUTELY NO MENTION OF A VENTRAL HERNIA, THIS DIAGNOSIS IS CERTAINLY QUESTIONABLE 2. THE VENTRAL HERNIA, IF ACTUALLY PRESENT, WAS NOT DETECTED UNTIL A 2009 EXAM. IF IT IS TO BE PRESUMED THAT THIS VENTRAL HERNIA WAS DUE TO THE STRESSES INCURRED DURING MILITARY SERVICE SOME 50 YEARS PRIOR, IT WOULD BE REASONABLE TO ASSUME THAT THIS MALADY WOULD HAVE PRESENTED SOONER THAN A REMOTE TIME FRAME, ESPECIALLY GIVEN THE HISTORY OF EMPLOYMENT LISTED. 3. THE DIAGNOSIS OF GERD PRECEDES THE DIAGNOSIS OF VENTRAL HERNIA BY A NUMBER OF YEARS AND THEREFORE CANNOT BE RELATED TO THE DEVELOPMENT OF GERD 4. I FIND NO CREDIBLE MEDICAL EVIDENCE OF AN INTESTINAL BLOCKAGE OTHER THAN THE REMOTE 1945 DIAGNOSIS AND NO CHRONICITY AS OUTLINED IN MY PREVIOUS OPINIONS ON THIS SUBJECT IN 2012 EXAM SO THEREFORE THE OPINION ON THIS SUBJECT AND VENTRAL HERNIA IS MOOT. 5. NUMEROUS CT'S OF ABDOMEN IN 2007 AND 2011 SHOW NO EVIDENCE OF VENTRAL HERNIA. The May 2014 VA examiner also concluded that it was less likely than not that the Veteran's gastrointestinal disorder manifested by GERD and intestinal blockage was proximately due to or the result of a service-connected condition. In so doing, the VA examiner provided the following rationale: 1. PLEASE SEE PREVIOUS OPINION IN REGARD TO VENTRAL HERNIA DIAGNOSIS 2. THERE IS NO MEDICAL EVIDENCE TO SUPPORT THAT THE GERD CONDITION HAS INCREASED IN SEVERITY. THE MEDICAL RECORDS REVIEWED SHOW NO CHANGES IN MEDICATION NOR FURTHER INVESTIGATION BY ANY MEDICAL PERSONNEL As reflected above, the record contains conflicting medical opinions on the question of whether the Veteran manifests a gastrointestinal disorder manifested by GERD and "intestinal blockage" which is proximately due to service-connected disability. In order to assess the relative probative value of the opinion for and against the claims, the Board must first evaluate the factual basis underlying these opinions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (discussing that important, guiding factors to be used by VA adjudicators in evaluating the probative value of a medical opinion include whether 1) the opinion is based upon sufficient facts or data, 2) the opinion is the product of reliable principles and methods and 3) whether the examiner has applied the principles and methods reliably to the facts of the case). As noted above, the Veteran's STRs do reflect delayed and protracted treatment for acute appendicitis. He first suffered from appendicitis in November 1944 initially treated with blunt dissection of appendix abscess, he underwent appendectomy in February 1945, and was discharged from the hospital in April 1945. However, the Veteran concedes that his gastrointestinal symptoms of constipation and recurrent epigastric distress did not manifest until approximately 50 years after his service discharge. In this context, a VA examiner in June 2006 found that the Veteran's "[c]hronic abdominal pain" was most likely secondary to adhesions formed after his initial abscess evacuation in 1944. Notably, this examination included abdominal series x-ray which was interpreted as showing nonspecific bowel gas pattern with a moderate-to-large amount of stool within the colon. The overall probative value of this opinion is reduced due to the fact that the VA examiner did not clearly state whether the Veteran's constipation and GERD symptoms were part and parcel of the "[c]hronic abdominal pain" caused by the surgical adhesions. Another VA examiner in November 2009 recorded the Veteran's complaint of bowel dysfunction manifested by constipation with alternating diarrhea in approximately 1997 as well as GERD symptoms. The examiner found the Veteran to have "diastasis/ventral hernia" on examination. Notably, this finding was difficult to observe in supine position but was "readily palpable" as the rectus muscles dislodged laterally when the Veteran coughed. This examiner found that the Veteran's "digestive problem" was at least as likely as not related to his abdominal wall musculature which had been stressed by military service. The overall probative value of this opinion is reduced due to the fact that the VA examiner did not clearly state whether the Veteran's constipation and GERD symptoms were part and parcel of the "digestive problem" caused by the ventral hernia. However, the examiner did refer to the "digestive disorder resulting from gastroparesis." As discussed above, gastroparesis is a disorder that slows or stops the movement of food from the stomach to the small intestine with symptoms which include nausea, a feeling of fullness after eating only a small amount of food, vomiting undigested food, GERD, pain in the stomach area, abdominal bloating and lack of appetite. On the other hand, the record includes the opinion from the July 2011 VA examiner who concluded that it is unlikely that GERD or an episode of apparent bowel obstruction was related to the in-service appendicitis. The probative value of this opinion is reduced as the claims file was not available to the VA examiner for review, and the examiner did not consider the significance, if any, of the service-connected ventral hernia. A July 2012 VA examiner opined that there was no evidence that an intestinal blockage or GERD began during active service, and that there was no medical reason to relate a remote appendectomy scar to any current claimed gastrointestinal issues. The probative value of this opinion is reduced as the VA examiner did not consider the significance, if any, of the service-connected ventral hernia. In an opinion dated May 2014, the July 2012 VA examiner found that it was less likely than not that the Veteran's gastrointestinal disorder manifested by GERD and intestinal blockage was proximately due to or the result of active service, or aggravated by service-connected ventral hernia. This examiner found that the prior diagnosis of ventral hernia was questionable as there were no other examinations or radiology results supporting the diagnosis. The examiner next stated that, presuming that a ventral hernia existed, this defect could not be medically related to GERD, which had been diagnosed earlier. The examiner also found no current disability manifested by intestinal blockage. The Board finds several defects in the May 2014 opinion which reduces its overall probative value. The Board first observes that the VA examiner found no current disability manifested by "intestinal blockage" which is technically correct, as the medical evidence of record reflects no treatment for, or diagnosis of, "intestinal blockage." However, the Veteran has repeatedly referenced recurrent episodes of constipation and has obtained medical treatment for constipation. In fact, the AOJ originally adjudicated an issue claimed as constipation/intestinal blockage. In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Court held that, in determining the scope of a claim, the Board must consider the claimant's description of the claim; symptoms described; and the information submitted or developed in support of the claim. Given this record, the Board construes the Veteran's lay reference to "intestinal blockages" to refer to his recurrent constipation symptoms. Thus, the May 2014 VA examiner's determination that the Veteran does not have a current disability manifested by "intestinal blockage" is inadequate for rating purposes. See McClain, supra. Second, the May 2014 VA examiner questioned the validity of the diagnosis of ventral hernia made by the November 2009 VA examiner. The May 2014 VA examiner's conclusion holds some probative value as it was rendered upon a review of the entire claims file. However, the November 2009 VA examiner noted that the ventral hernia was not easily detectable but "readily palpable" as the rectus muscles dislodged laterally when the Veteran coughed. Unfortunately, the May 2014 examiner did not examine the Veteran in an effort to confirm whether a ventral hernia was present. A review of the July 2012 examination report, wherein an examination was performed, did not reflect that the VA examiner attempted to replicate the findings from the November 2009 VA examination. Thus, the opinion questioning the presence of a ventral hernia is inadequate as it was not based upon all procurable data-such as actual examination of the Veteran specifically attempting to replicate the November 2009 examination findings. See Jones (Michael) v. Shinseki, 23 Vet. App. 382, 390 (2010) (examination opinion should clarify whether inability to come to conclusion was based on all "procurable and assembled data." and/or the whether the inability to provide a definitive opinion was due to a need for further information or because the limits of medical knowledge had been exhausted regarding the etiology of the disorder). Finally, the May 2014 VA examiner concluded that, assuming a ventral hernia existed, GERD could not be caused by the ventral hernia as GERD had been diagnosed earlier. However, as indicated above, the November 2009 VA examiner essentially concluded that the ventral hernia was not easily detectable. It would logically appear to the Board that the Veteran's ventral hernia detected on VA examination in November 2009 existed prior to that date (the date of diagnosis), but there is no reliable information of record to determine the onset of the ventral hernia. Thus, the reasoning for this opinion appears to be based on speculation, and the opinion is not entitled to significant probative weight. The Board observes that it is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. See also 38 U.S.C.A. § 5107(b). Carefully considering the evidence of record in light of the applicable legal authority, the Board finds that the June 2006 opinion that the Veteran's "[c]hronic abdominal pain" was most likely secondary to adhesions formed after his initial abscess evacuation in 1944 and the November 2009 VA examiner's opinion that the Veteran's "digestive problem"/gastroparesis is proximately due to service-connected ventral hernia places the competent, probative medical opinion evidence of record in relative equipoise on the question of whether the Veteran's chronic abdominal pain and gastroparesis, to include constipation and GERD, are due to service-connected origin. Resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's gastrointestinal problems, including GERD and intestinal blockages, are proximately due to or the result of his service-connected ventral hernia. Accordingly, the criteria for secondary service connection are met. ORDER Service connection for a gastrointestinal disability manifested by GERD and intestinal blockage, as secondary to service-connected ventral hernia, is granted. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs