Citation Nr: 1819084 Decision Date: 03/30/18 Archive Date: 04/05/18 DOCKET NO. 97-25 887 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for chronic liver disability. 2. Entitlement to service connection for gastritis. 3. Entitlement to service connection for esophagitis. 4. Entitlement to service connection for kidney disability. REPRESENTATION Appellant represented by: Arizona Department of Veterans Services ATTORNEY FOR THE BOARD Bridgid D. Houbeck, Counsel INTRODUCTION The Veteran served on active duty from August 1963 to August 1966. This matter comes to the Board of Veterans' Appeals (Board) on appeal from October 1996, June 2003, and March 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. The October 1996 rating decision, in relevant part, denied the Veteran's attempt to reopen a claim of service connection for chronic liver disease secondary to acute infectious hepatitis, which had been originally denied in Mary 1979. The June 2003 rating decision denied service connection for gastritis. The March 2014 rating decision denied service connection for esophagitis and kidney condition. The Board adjudicated this appeal in a December 2015 decision by reopening the issue of service connection for chronic liver disability and denying the Veteran's claims of service connection for gastritis, esophagitis, chronic liver disability, and kidney disability. The Veteran appealed the denials of service connection in that that decision to the U.S. Court of Appeals for Veterans Claims (Court). In a May 2017 Memorandum Decision, the Court vacated the December 2015 decision and remanded the claim to the Board for action consistent with the decision. The issue of service connection for kidney disease is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran does not have a chronic liver disability that is related to his active service. 2. The Veteran's gastritis is not related to his active service and was not caused or aggravated by a service connected disability. 3. The Veteran's esophagitis is not related to his active service and was not caused or aggravated by a service connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for chronic liver disability have not all been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017). 2. The criteria for service connection for gastritis have not all been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017). 3. The criteria for service connection for esophagitis have not all been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See generally, 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159, 3.326 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). II. Evidence The Veteran's service treatment records show that he was hospitalized for 47 days, from August 10, 1964 to September 26, 1964, for infectious hepatitis. The onset of his symptoms was eight days earlier and his initial complaint was epigastric pain. This was treated and improved. In January 1965 the Veteran underwent a chest x-ray, which found no significant abnormality. The Veteran testified at his November 2014 decision review officer (DRO) hearing that the VA examiner ignored additional references to gastritis in his service treatment records. Additionally, he has submitted annotated copies of his service treatment records. He specifically highlighted a November 6, 1964 record that notes vague lower abdominal pain. The Veteran's notations include reference to dyspepsia and "doctor states gastortitis cramped." A review of this record shows that the Veteran had been diagnosed with gonorrhea (GC) two weeks prior and was treated with massive penicillin. For the prior week he had intermittent episodes of dysuria (not dyspepsia) without urethral discharge. This was associated with vague lower abdominal pain. With regard to the comment that he read as gastritis, the notation is "P.E. - ext genitals - circumcysed, one well healed small lesion on scrotum." This is a notation as to the physical examination of the external genitals and does not deal with his gastrointestinal system at all. The Veteran has also annotated a record from later that month, November 13, 1964, which shows that he was convalescing from infectious hepatitis at the time and complained of constant gas in stomach. At that time he had no specific genitourinary (G-U) complaints. The Veteran writes that this record says "chronic and persistent pain," but the entry he highlights prescribes charcoal and peppermint. In a third service treatment record from November 24, 1964, the Veteran misreads the notations of "no g-i (gastrointestinal) distress now, no g-u (genitourinary) symptoms" as saying more gastritis symptoms. In his July 1966 separation Report of Medical History, the Veteran denied stomach, liver, or intestinal trouble. He did report a history of jaundice, shortness of breath, frequent colds, shortness of breath, and painful joints. His accompanying medical examination was normal except for his lungs, with wheezing and rhonchi noted. A March 1979 letter from the Veteran's cardiologist, Dr. W.E.D., noted that he had seen the Veteran in November 1973 for a routine physical examination. The Veteran had not particular complaints at that time except that he was suffering from a hangover and complained bitterly. The Veteran agreed that he probably had been drinking excessively every three to four days, but otherwise had no real complaints. He did describe some nonspecific chest pains of a shooting jabbing nature and of a particular sensitive sensation in his legs if he had no alcoholic beverages for any particular period of time. His past history revealed an episode of hepatitis in 1964 which he stated made him sick for three months. The remainder of his history was unremarkable. Physical examination of the abdomen revealed the liver was down one fingerbreadth and was quite tender to palpation but otherwise felt normal. There was no other viseromegaly and no other findings. Labwork included normal electrocardiogram, healthy chest x-ray, normal CBC, and negative urinalysis. Dr. W.E.D. advised the Veteran that his alcohol use was a real social problem and he should discontinue use of alcohol. In his recent annotations, the Veteran argues that he did not go for a physical in 1973, as stated by Dr. W.E.D., but rather he was seeking treatment for constant stomach pain at that time. At his November 2014 DRO hearing, the Veteran testified that this doctor had altered his record in response to the Veteran leaving the hospital without his permission. The Veteran has not provided any evidence to corroborate this claim. The Board presumes that medical professionals will accurately report a patient's history regardless of perceived personal slights and so the Veteran's unsupported accusations to the contrary are insufficient to render this record not credible. In his original February 1979 claim, the Veteran reported an enlarged liver ever since his hepatitis in service. He stated that three doctors had confirmed this since his separation from service. He was unable to digest food well, was overly tired, and vomited periodically. A February 1979 treatment record shows the Veteran's complaints of gas, vomiting, and burning for one month. He also reported epigastric and abdominal discomfort that was eased by eating. He had vomited in the morning for five years. This record notes a history of hepatitis several years earlier and a history of moderate alcohol use. An upper gastrointestinal series later that month was normal, specifically finding no esophageal abnormalities and a normal stomach. An August 1991 upper gastrointestinal tract radiography found gastroesophageal reflux disease (GERD) and dyspepsia. VA treatment records throughout the pendency to this claim show complaints of dyspepsia, epigastric discomfort, diarrhea, constipation, abdominal pain, and gastritis. His diagnoses included Schatzki's ring with a small hiatal hernia (February 1999 barium swallow), GERD, dysphagia, and gastritis. Treatment records for January 1996 note complaints of epigastric pain and constipation and a history of gastritis. He was diagnosed with GERD and gastritis. The treatment plan included a hepatitis chronic panel. In September 1996 the Veteran underwent a VA general medical examination. At that time his chief complaint was inability to remember and this poor memory had led to the loss of his job the prior year. He also stated that he had had epigastric distress all his life and had been diagnosed with gastritis. He occasionally blacked out and had been told that he had elevated liver enzymes. Physical examination revealed that his abdomen was soft with no masses or tenderness. In May 1997 the Veteran underwent a VA cognitive assessment for competency which notes that the Veteran's thinking is poorly organized, vague, and tangential. It was easily deteriorated with stress. He was quite suggestible and easily influenced by affective elements in his environment. A later May 1997 treatment record noted that the Veteran thought his stomach problems were related to his gallbladder. An August 1997 ultrasound noted slightly heterogeneous increased echogenicity suggestive of and consistent with fatty infiltration of the liver. There were no intrahepatic masses or dilation of the intrahepatic biliary system. The gallbladder wall was not thickened and there were not stones or sludge within the gallbladder. In a January 2002 VA record, the Veteran's social worker noted that he was making several attempts to contact the Veteran's daughter to obtain additional information on the Veteran's behavior, medication compliance, legal problems, finances, living arrangements, friends, and how he spent his time, because the Veteran was known to be a poor historian. A May 2003 memorandum from the Veteran's prior representative noted that the Veteran's multiple physical and mental disabilities rendered him a very poor historian. This comment was made within the context of trying to recall the dates of his VA treatment for gastritis. The Veteran underwent a VA examination in September 2009. This examiner, Dr. E.R., reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation. This examiner diagnosed the Veteran with inflammation of the esophagus, stomach, and/or duodenum. This examiner noted that the Veteran had been hospitalized and treated for hepatitis during service. His service treatment records did not note any gastrointestinal symptoms after that hospitalization. There was no in-service diagnosis of chronic gastritis and no symptoms, treatment, or physical findings to suggest that the Veteran had inflammation of the esophagus, stomach, and/or duodenum during service. The Veteran was treated for "gas in stomach" in 1964, but that lay terminology was so nonspecific as to be meaningless, especially in a person who had been consuming alcohol. There was nothing to suggest that that terminology would be related to the Veteran's current problem, and it would be unreasonable to assume that it was. Additionally, he noted that inflammation of the esophagus, stomach, and/or duodenum were unrelated to the Veteran's in-service infectious hepatitis. In a May 2011 addendum opinion, the September 2009 VA examiner noted the Veteran's continued complaint of constant substernal burning pain, which became worse at night and increased whenever he ate. He reported that Omeprazole did not relieve his symptoms. Both liquid and solid foods got stuck in his mouth and he had to drink some liquid material to have it to go further down into his stomach. He had regurgitation almost every night, sometimes two or three times per night, which consisted of partially digested food. A June 2007 esophagogastroduodenoscopy revealed duodenitis because of erosions of the mucosa. He also had a nodule of his esophagus removed, which was an inflammatory polyp. He had inflammation and erythema of the esophagus. At that time, a diagnosis of esophagitis and duodenitis was made. His current symptoms were more compatible with esophagitis than duodenitis. The Veteran did not have any symptoms in the upper portion of the abdomen; his symptoms were substernal. Examination of his abdomen revealed it to be protuberant. No organ masses or tenderness was palpable. The current diagnoses were esophagitis with GERD. The examiner confirmed his September 2009 opinion. The medical evidence "tab A" was not a part of the claims file at the time of his September 2009 opinion, but was reviewed prior to the final addendum opinion. This examiner reviewed that information, noting that they were post military medical records. He then opined that the Veteran's current esophagitis was unrelated to his military service as the Veteran received no treatment for esophagitis while in the military and had no symptoms suggestive of esophagitis while in the military. He did have hepatitis in service, but hepatitis does not lead to esophagitis or is not related to esophagitis and is anatomically unrelated to the esophagus. A November 2010 VA treatment record notes the Veteran's complaints that he had not been feeling well since he kissed a woman with hepatitis C a week earlier. April 2011 VA treatment records show that the Veteran complained of stomach problems and had requested a hepatitis panel. He stated that he had read an article that hepatitis B could cause his problems. He also stated that his fatty liver could be causing the problems. The registered nurse asked about his fatty liver disease as it was not in his medical record and he stated that it was all through his chart and one time his liver enzymes were elevated. The Veteran had undergone liver enzymes as recently as the prior December, so his physician though it very unlikely that his symptoms stemmed from hepatitis. The more likely culprit was his GERD. He was on omeprazole and if he still had reflux and abdominal pain, this physician suggested referral for esophagogastroduodenoscopy. February 2013 private labwork shows negative hepatitis B surface antigen and abnormal hepatitis B surface antibody. The Veteran was diagnosed with dyspepsia. An April 2013 VA treatment record notes the Veteran's chronic abdominal pain and his worry that his gastrin level was too high (164). He was informed that that value was not unusual in the setting of taking a proton-pump inhibitor. In a November 2013 opinion, Dr. C.N.B., found that all of the Veteran's claimed conditions (gastritis, esophagitis, live, and kidney) were due to his military service. In doing so, this physician found that the Veteran had a chronic form of hepatitis, likely hepatitis B and a chronic form of gastritis secondary to his chronic hepatitis. Dr. C.N.B. found that the records did not support a more plausible etiology for the Veteran's current gastrointestinal problems and that the lag time between the Veteran's hepatitis in service and his current pathology was consistent with known medical principles and the natural history of the disease. This opinion was based in part on the Veteran's reported medical history, which Dr. C.N.B. found to be credible with many of his historical details corroborated by lay testimony. Notably, Dr. C.N.B. refers to the Veteran's report that the reason for his January 1965 chest x-ray was a complaint of gastric pain and his report of recurrent upper gastrointestinal problems and belly pain since service. Additionally, Dr. C.N.B. notes the small amounts of bilirubin and urobilinogen in his September 2012 and December 2012 uranalysis and elevated levels of gamma-glutamyl transferase (GGT) and liver enzymes dating back to January 1993, the Veteran's abstinence from alcohol since 1985. Confusingly, Dr. C.N.B. references a medical journal which concludes "In patients infected with hepatitis C, the majority of fibrosis progression occurred in those aged fifty or older." As the record does not show that the Veteran has or ever had hepatitis C, the Board is unclear how this article supports the doctor's findings regarding his in-service diagnosis of hepatitis B. Additionally, Dr. C.N.B. found that the Veteran's gastritis was very likely causing his GERD, which in turn was causing esophagitis, noting that his medical record did not contain another more likely cause for these conditions. He noted that esophageal varices occur most often in people with serious liver disease. Additionally, the Veteran had a small bowel overgrowth and duodenitis, which was a digestive condition where the area of the small intestine that connects to the stomach becomes irritated and inflamed, inevitably affecting digestion. Chronic hepatitis B resulted in disharmony between the liver and stomach. Dr. C.N.B. also disagreed with the August 1997 ultrasound findings that suggested fatty infiltration of the liver, stating that he believes the cause of the increased echoes at that time was the Veteran's history of hepatitis in service that had not resolved. In their lay statements, the Veteran's daughters D.F. and A.D. stated that the Veteran has constant stomach pain for many years dating back as long as A.D. could remember and that he had not drank alcohol since approximately 1985. The record shows D.F. was born in 1969 and A.D. was born in 1973. The Veteran's daughters were born after his separation from service and therefore are unable to provide lay evidence of ongoing symptoms since that time except to reiterate the Veteran's own account. While they may provide credible evidence of these long-standing symptoms, they are not competent to provide evidence of his symptoms prior to their births. In an October 2014 statement, the Veteran's ex-wife reported that he was seen by VA in 1968 or 1969 for constant stomach pain and x-rays showed gastritis. He filed a claim in 1970 or 1973 but was denied. The Veteran continued to have chronic stomach pain. The record shows that the Veteran and his ex-wife were married in September 1966, shortly after his separation from service. She stated that they remained married for 18 years. As such, she is competent to provide lay evidence of the Veteran's symptoms in 1968 or 1969. She had not provided lay evidence of the onset of these symptoms beyond stating that he sought treatment a couple years after his separation from service. At his November 2014 DRO hearing, the Veteran reported that he had low vitamin D, which he believed indicated liver disease. He also stated that he had lupus. He testified that his immune system had been low ever since he contracted hepatitis in service, which led to gastritis and bronchitis. He attributed all of his claimed conditions with hepatitis B. His daughter testified that the Veteran had had stomach problems her entire life. The Veteran underwent another VA examination in conjunction with this claim in January 2015. This examiner reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation, then offered an opinion as to the nature of the claimed disability, accompanied by a rationale. Therefore, this examination is adequate for VA purposes. At that time, the Veteran reported a fifty year history of epigastric distress. The January 2015 VA examiner noted a history of hepatitis, diagnosed in 1964, but found no current signs or symptoms attributable to a chronic or infectious liver disease, cirrhosis of the liver, biliary cirrhosis, or cirrhotic phase of sclerosing cholangitis. The Board notes that the Veteran has returned a copy of this examination with the "cirrhotic phase of sclerosing cholangitis" portion of the Section II heading underlined. This examination clearly does not diagnose the Veteran with that condition as the examiner answered the question immediately below negatively. This examiner then provided a negative opinion finding that the Veteran's current gastrointestinal disability (gastritis) was less likely as not related to his service, noting that the VA treatment records did not include a diagnosis of chronic active hepatitis and stating that the possible causes of this condition were instead his history of alcohol consumption prior to 1985, prior medications, cigarette smoking, other viruses and bacteria, and genetics. This examiner noted a January 2013 finding of elevated gastrin levels, which causes gastritis and has a genetic basis. In an August 2015 letter, Dr. H.M. found that the Veteran had chronic hepatitis B based on jaundice in service; laboratory evidence of hepatitis B dated September 2011, February 2013, and April 2015; and Dr. C.N.B.'s letter stating that the Veteran had hepatitis in service. During the Veteran's appeal to the Court, he submitted additional medical treatment records labeled as VA records, but were not included in the VA treatment records provided by the Phoenix VA Medical Center. These records include bloodwork from February 1996, a September 2011 liver ultrasound, and an April 2015 MRI. The September 2011 record notes a clinical history of hepatitis B. The findings noted scattered specular reflectors suggesting granulomatous calcifications, previously noted nine years earlier. The Veteran's liver and spleen were otherwise unremarkable with no dominant mass identified. The April 2015 record lists the reason for study as rule out liver mass has chronic hepatitis B. The MRI found the Veteran's liver to be normal in morphology and signal. No enhancing hepatic masses were identified. There was no acute intra-abdominal abnormality. No diagnostic code was assigned. III. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2017). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). "In the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Further, the requirement of a current disability is satisfied if the disability existed at the time a claim of filing of VA disability compensation or during the pendency of that claim, even if the disability resolved prior to adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). A diagnosis dated prior to the filing of a claim is relevant evidence in determining whether a current disability existed at the time the claim was filed or while the claim was pending, and it may support the existence of a current disability at the time of claim filing if it was close enough in time under the circumstances of the case. See Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). Service connection may also be established under 38 C.F.R. § 3.303 (b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303 (b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). The Veteran is not claiming service connection for one of these specifically listed chronic diseases. Alternately, service connection may be granted, on a secondary basis, for a disability, which is proximately due to, or the result of an established service-connected disorder. 38 C.F.R. § 3.310. Similarly, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice- connected disease, will be service connected. Allen v. Brown, 7 Vet. App. 439 (1995). In the latter instance, the nonservice-connected disease or injury is said to have been aggravated by the service-connected disease or injury. 38 C.F.R. § 3.310. In cases of aggravation of a veteran's nonservice-connected disability by a service-connected disability, such veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.322. A. Chronic Liver Disability In this case, the weight of the record is against a finding of chronic hepatitis. The medical evidence does not corroborate the findings of the November 2013 and August 2015 private opinions. The Veteran's treatment records do not include findings of chronic hepatitis. The records cited by Dr. H.M. refer to hepatitis B in passing and do not appear to show a clinical diagnosis of this condition. Furthermore, the record does not show that either Dr. C.N.B. or Dr. H.M. performed any testing or examination to independently diagnose the Veteran with hepatitis B. Instead, they both rely on VA treatment records that they describe as showing active hepatitis. The VA treatment records do not show a current diagnosis of active hepatitis, as confirmed by the January 2015 VA examiner. The recently submitted September 2011 ultrasound and April 2015 MRI report both show no liver masses. The private doctors have not explained how these records establish a current diagnosis of hepatitis B when the contemporaneous medical records fail to show such a diagnosis and the results of both tests are findings of a generally normal liver with long-standing granulomatous calcifications. Therefore, the Board finds that the Veteran does not have a current diagnosis of hepatitis B. Furthermore, although the Veteran reported a history of elevated liver enzymes and fatty liver during VA treatment in April 2011, his physician specifically noted normal liver enzymes when tested in December 2010. Additionally, the January 2015 VA examiner specifically found no current signs or symptoms attributable to a chronic or infectious liver disease, cirrhosis of the liver, biliary cirrhosis, or cirrhotic phase of sclerosing cholangitis. As such, the record does not show a current liver disability. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for chronic liver disability. Thus, this claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. B. Gastritis and Esophagitis As noted above, the Veteran has current diagnoses of gastritis and esophagitis/GERD. His service treatment records show treatment for acute hepatitis from August 1964 to September 1964. In November 1964, while convalescing from infectious hepatitis, the Veteran complained of constant gas in stomach. Although the Veteran has argued that his service treatment records show additional gastric complaints, the Board does not find that to be the case, as detailed above. The remaining question is whether the Veteran's current gastritis and/or esophagitis/GERD is causally related to his in-service acute hepatitis or November 1964 complaint of stomach gas. To that end, the VA examiners have consistently found that the Veteran's current gastritis and/or esophagitis/GERD are not related to his military service. The September 2009 VA examiner found that the Veteran's current inflammation of the esophagus, stomach, and/or duodenum were unrelated to the Veteran's in-service infectious hepatitis and complaint of "gas in stomach" in November 1964, noting that the November 1964 terminology was meaningless due to lack of specificity and the Veteran's use of alcohol and the service treatment records did not note any gastrointestinal symptoms after that hospitalization. In his May 2011 addendum opinion, the September 2009 VA examiner found that the Veteran's current esophagitis was unrelated to his military service as the Veteran received no treatment for esophagitis while in the military and had no symptoms suggestive of esophagitis while in the military. He did have hepatitis in service, but hepatitis does not lead to esophagitis or is not related to esophagitis and is anatomically unrelated to the esophagus. The January 2015 examiner provided a negative opinion finding that the Veteran's current gastritis was less likely as not related to his service, noting that the VA treatment records did not include a diagnosis of chronic active hepatitis and stating that the possible causes of this condition were instead his history of alcohol consumption prior to 1985, prior medications, cigarette smoking, other viruses and bacteria, and genetics (associated with elevated gastrin levels). Dr. C.N.B.'s positive opinion relied on a causal chain to establish secondary service connection, as discussed below. Thus, the record does not contain a positive medical nexus opinion establishing direct service connection for gastritis or esophagitis. Turning to the lay evidence of his ongoing symptoms, the Board notes that the Memorandum Decision specifically noted the prior decision's failure to analyze the credibility of the statements of the Veteran's ex-wife and daughters. In this case, the Veteran is not diagnosed with a chronic condition under 38 C.F.R. § 3.303 (b) for which service connection may be established based on continuity of symptomatology. As such, even accepting these lay statements of stomach symptoms dating back to 1968, in the case of the Veteran's ex-wife, and continuing throughout the lifetimes of his daughters as entirely credible, they are insufficient to establish service connection for either current condition. To the extent that the Veteran has provided a lay opinion of etiology, stating that his symptoms began with his in-service hepatitis and have continued ever since, the Board finds this evidence not compelling. The Veteran is competent to provide lay evidence of his symptoms, but he is not shown to have the requisite medical knowledge, skills, or training to differentiate symptoms associated with his current gastritis and/or esophagitis from those associated with his drinking in the past. Furthermore, that lay evidence of ongoing symptoms since service is not found to be credible. First, the contemporaneous medical evidence contradicts his current claims as he was shown to have recovered from his hepatitis prior to his separation from service without additional related complaints. According to Dr. W.E.D., his only complaints in 1973 were nonspecific chest pains of a shooting jabbing nature and of a particular sensitive sensation in his legs if he had no alcoholic beverages for any particular period of time. He was advised to discontinue drinking alcohol. The first post-service medical record of epigastric discomfort and abdominal pain is dated February 1979. An upper gastrointestinal series later that month was normal, specifically finding no esophageal abnormalities and a normal stomach. Second, the record repeatedly shows that the Veteran is a poor historian and confuses the record. The record does not suggest malicious intent, but does repeatedly show for example that the Veteran believes that his records provide a history that is directly contradictory to the records themselves. As such, the Board finds the Veteran's lay evidence of etiology significantly less probative than the medical evidence of record. Service connection may also be established under 38 C.F.R. § 3.303 (b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303 (b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). The Veteran is not claiming service connection for one of these specifically listed chronic diseases. The Board notes that Dr. C.N.B. found that the Veteran had chronic hepatitis B, which led to chronic gastritis, which in turn led to GERD, which led to esophagitis. Service connection has not been established for chronic hepatitis. Furthermore, as explained above, the record does not support a finding of chronic hepatitis. As the causal chain described by Dr. C.N.B. begins with a finding of chronic hepatitis since service and chronic hepatitis is not shown, the remaining disabilities are not linked to the Veteran's military service. As such, service connection on a secondary basis is not warranted. For the reasons stated above, the Board finds that the preponderance of evidence is against the Veteran's claims of entitlement to service connection for gastritis and esophagitis. Thus, his appeal must be denied. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for chronic liver disability is denied. Service connection for gastritis is denied. Service connection for esophagitis is denied. REMAND As noted in the May 2017 Court remand, a VA examination is necessary for the claim of service connection for a kidney disability. The Veteran has submitted evidence suggesting a current diagnosis of stage 2 chronic kidney. He was treated for hepatitis in service. Therefore a medical examination and opinion are necessary to address whether the Veteran's current kidney condition is causally related to his in-service hepatitis. Accordingly, the case is REMANDED for the following action: 1. Ensure that the Veteran is scheduled for a VA examination by an appropriately qualified examiner to with regard to any current kidney condition. The claims file must be reviewed by the examiner and the examiner must note whether the claims file was reviewed. All indicated studies should be conducted, and all findings reported in detail. Provide a medical opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any kidney condition began in or was otherwise causally related to his military service, to include his hepatitis B during service. The examiner must support any and all opinions with a rationale. If the examiner cannot provide the above opinion, the examiner is advised that he/she should explain why the requested opinion cannot be provided (i.e., because the limits of medical knowledge had been exhausted or because further information to assist in making the determination is needed, such as additional records and/or diagnostic studies. If the examiner cannot provide the answer because further information is needed to assist in making the determination, all reasonable steps to obtain this missing information should be exhausted before concluding that the answer cannot be provided. 2. After completion of the above and any additional development deemed necessary, readjudicate the claim of service connection for a kidney condition. If the benefit sought is not granted, furnish to the Veteran and his representative a supplemental statement of the case and allow an appropriate opportunity to respond before returning the case to the Board. 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 claim 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 Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ JAMES G. REINHART Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs