Citation Nr: 1815131	
Decision Date: 03/13/18    Archive Date: 03/19/18

DOCKET NO.  15-44 773	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Louisville, Kentucky


THE ISSUE

Entitlement to service connection for hemorrhoids.


REPRESENTATION

Appellant represented by:	The American Legion


ATTORNEY FOR THE BOARD

A. Yaffe, Associate Counsel







INTRODUCTION

The Veteran served on active duty from June 1952 to June 1956.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2011 rating decision of the Department of Veterans Affairs (VA) in Louisville, Kentucky. 

In January 2013, the Board remanded the appeal.  In November 2017, the Board denied service connection for a right knee disability, sinusitis, and a skin disorder, and remanded the hemorrhoid claim.  The remaining claim has since returned for further appellate consideration.

This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017).  38 U.S.C. § 7107(a)(2) (2012).

FINDING OF FACT

The competent evidence does not demonstrate that Veteran's preexisting hemorrhoids, noted at entry to service, were permanently aggravated by service.

CONCLUSION OF LAW

The criteria to establish service connection for hemorrhoids are not met.  38 U.S.C. §§ 1110, 1131, 1153, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.306 (2017).


REASONS AND BASES FOR FINDING AND CONCLUSION

Preliminary Matter

The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record.  See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). 

Applicable Laws and Regulations

Where a preexisting disease or injury is noted on the entrance examination, section 1153 of the statute provides that "[a] preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease."  38 U.S.C. § 1153 (2012); 38 C.F.R. § 3.306(a).  Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition itself, as contrasted with mere symptoms, has worsened.  See Jensen v. Brown, 4 Vet. App. 304, 306 -07 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991).

VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a).  Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.  Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).  Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence.  Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006).

Analysis

The Veteran asserts that his hemorrhoids are related to service.  Upon entrance to active duty, a June 3, 1952 enlistment examination noted no abnormalities; however, a June 5, 1952 processing examination two days later, as part of the enlistment process noted that the Veteran had "enternal [sic] hemorrhoids dry NSND."  Accordingly, the Veteran had hemorrhoids that preexisted his military service.  

When a disease or injury is noted on entry, the burden shifts to the Veteran to show by a preponderance of the evidence that the disease or injury was aggravated by service.  The Veteran's subsequent STRs are silent to any complaints, treatments, or diagnosis of hemorrhoids.  Notably, Reports of Medical History dated in March 1956 during active duty, and March 1961 and August 1964 during Reserve service indicate that the Veteran himself denied any "piles or rectal disease" and none were noted on the respective examination reports.  Moreover, the Veteran's June 1956 separation examination report is silent to any complaints, treatment, or diagnosis of hemorrhoids.  In fact, the examiner noted that the anus and rectum, to include hemorrhoids were "normal."    

Post-service medical treatment records are silent for any complaints, treatments, or diagnoses of hemorrhoids. 

Subsequent to the Board's November 2017 remand, the Veteran underwent a VA examination later that month, where the examiner indicated that the Veteran was demented and most of the history was reviewed and gathered with the help of his spouse.  The examiner further indicated that the Veteran's STRs and claims folder were reviewed.  The Veteran's spouse reported that he would complain of hemorrhoidal pain once or twice a year, and would take a preparation H suppository, which would resolve the problem.  The Veteran never had any rectal surgeries, sclerotic therapies, or any other procedure for hemorrhoids.  

The examiner diagnosed a mild internal hemorrhoid and small external hemorrhoid, with no heme on blood, no anal fissures/pathology.  There were no scars.  The examiner indicated that the Veteran did not have constant hemorrhoidal pain, but rather, only one or two times a year over the previous 20 years.  It was further noted that the Veteran was currently at a nursing center for Alzheimer's disease, and a 

review of his medical chart showed no diagnosis or treatment for a rectal condition, to include hemorrhoids.  There was no evidence of thrombosis, significant hemorrhage/CBC/ablations, or surgeries in the past six and half decades since 1952.  

The examiner stated that the examination revealed a single internal and a single external hemorrhoid, leaving no blood on glove (not actively bleeding) upon palpation.  The examiner opined that there was no increase in severity of the Veteran's internal hemorrhoid that pre-existed service.  The examiner explained that the only notation in the Veteran's STRs was during his June 1952 enlistment examination, and throughout service, the Veteran constantly denied any "piles or rectal disease," to include during his June 1956 separation examination.  The examiner further indicated the Veteran's STRs are silent treatments or complaints of blood in stool, rectal pain, or report of hemorrhoid of any kind.  Furthermore, the examiner stated that post-service medical treatment notes are also silent to any complaints or treatment of prolapse, thrombosis, or significant hemorrhage.  The examiner concluded that the medical record is completely silent to any reports of hemorrhoids, aside from the June 1952 enlistment examination. 

The VA medical examiner further opined that the Veteran's current diagnosis of hemorrhoids was less likely incurred in, or caused by, the hemorrhoids in-service.  The examiner explained that while external hemorrhoids were noted on examination, hemorrhoidal veins were normal anatomic structures located in the submucosal layer in the lower rectum, and may be external or internal based upon whether they are below or above the dentate line.  It was also noted that both types of hemorrhoids often coexist, where external hemorrhoids arise from the inferior hemorrhoidal plexus, and covered by modified squamous epithelium, which contains numerous somatic pain receptors, making external hemorrhoids extremely painful on thrombosis.  The examiner further stated that internal and external hemorrhoids communicate with one another and drain into the internal pudendal veins, and ultimately the inferior vena cava.  In this regard, the examiner noted that the Veteran's internal hemorrhoids and increased venous return pressure would likely flow collaterally through the venous plexus, and both types would eventually drain into the vena cava from the superior and inferior hemorrhoidal veins.  The examiner concluded that there was no aggravation, casual or proximal relationship 

to the non-symptomatic, non-disabling hemorrhoids noted in-service, as the Veteran's current condition is the same six-and-half decades later. 

Accordingly, the Board finds the evidence does not show an increase in severity of the underlying condition, and therefore, aggravation of the hemorrhoids during service has not been shown.  "Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record."  38 C.F.R. § 3.306(b).

The Board recognizes the Veteran's belief that his hemorrhoids are related to his military service.  While he is competent to report his observable hemorrhoidal symptoms, he is not competent to provide a medical opinion that his hemorrhoids were permanently aggravated during service because he is not shown to possess the requisite medical training.  Thus in this case, the competent medical evidence outweighs the lay contentions regarding etiology.

In summary, service connection for hemorrhoids is not warranted, as the condition was noted at entry into service and was not shown to be aggravated by service.  Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable.  See 38 U.S.C. § 5107(b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990).  For these reasons, the claim is denied.

ORDER

Entitlement to service connection for hemorrhoids is denied. 



____________________________________________
S. B. MAYS
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs