Citation Nr: 1809328 Decision Date: 02/14/18 Archive Date: 02/27/18 DOCKET NO. 14-22 053 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for gastroesophageal reflux disease (GERD). 2. Entitlement to service connection for hypertension. REPRESENTATION Veteran represented by: Oregon Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD K. Lynch, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1969 to October 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office. A Board hearing was held in October 2016. A transcript is of record. FINDINGS OF FACT 1. The medical evidence of record indicates that the Veteran's GERD is etiologically related to medications used to treat his service-connected left shoulder disability. 2. The medical evidence of record indicates that the Veteran's hypertension is etiologically related to medications used to treat his service-connected left shoulder disability. CONCLUSIONS OF LAW 1. The criteria for service connection for GERD have been met. 38 U.S.C. § 1131 (2012); 38 C.F.R. §§ 3.303, 3.310 (2017). 2. The criteria for service connection for hypertension have been met. 38 U.S.C. § 1131 (2012); 38 C.F.R. §§ 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran asserts that he has GERD and hypertension as a result of medications used to treat his service connected left shoulder disability. For the reasons discussed below, the Board finds that service connection for GERD and hypertension is warranted. See 38 C.F.R. § 3.310 (2017). A disability can be service-connected on a secondary basis if proximately due to, or the result of, a service-connected condition. See 38 C.F.R. § 3.310(a) (2017). In order to establish entitlement to service connection on a secondary basis, there must be (1) a current disability; (2) a service-connected disability; and (3) a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable. 38 C.F.R. § 3.310(a) (2016); Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Veteran has current diagnoses of GERD and hypertension. See May 2014 VA examination. The first Wallin element has been satisfied. The Veteran is also service-connected for a left shoulder disability. See November 1972 rating decision. The second Wallin element has also been met. The key issue in this case is the third Wallin element. The Veteran contends that non-steroidal anti-inflammatory drugs (NSAIDS), specifically Ibuprofen, which he takes to treat his left shoulder pain have caused him to develop GERD and hypertension. See September 2009 statement in support of claim. There are multiple medical opinions of record with respect to the etiology of the Veteran's GERD and hypertension, some of which find a relationship between NSAIDS and the Veteran's GERD and hypertension, and others that do not. In the May 2014 VA examination, the examiner provided opinions regarding the etiology of the Veteran's GERD and hypertension. Regarding GERD, the examiner opined that it was less likely than not that the Veteran's GERD was due to, or the result of, his service-connected left shoulder. The examiner explained that GERD is caused by mechanisms in the lower esophageal sphincter that are not related to NSAIDs. The examiner stated that a June 2013 endoscopy indicated a hiatal hernia, which could contribute to the Veteran's GERD. The examiner stated that it is more likely that the Veteran's GERD is caused by mechanisms in the lower esophageal sphincter and hiatal hernia that are not related to NSAIDs and that the GERD is less likely due to chronic NSAID usage. Regarding hypertension, the May 2014 VA examiner opined it was less likely than not that the Veteran's hypertension was proximately due to, or the result of, the Veteran's service-connected left shoulder. Citing medical sources, the examiner noted that the Veteran's treatment notes support and documentation of primary (essential) hypertension to include "benign essential hypertension" in private treatment records and "unspecified essentially hypertension in VA treatment records. As such, the examiner stated that the evidence supports the diagnosis of primary (essential) hypertension. The examiner opined that the Veteran's hypertension is more likely primary or essential hypertension and less likely secondary hypertension due to NSAID use, stating that primary hypertension is not caused by NSAID usage. See May 2014 C&P exam, pp. 6-8. However, there are numerous positive medical nexus opinions relating the Veteran's GERD and hypertension to NSAIDs that the Veteran takes for his service-connected left shoulder disability. In November 2009, Dr. R stated that he had been treating the Veteran for the previous 5 to 6 years. Noting that the Veteran had been taking NSAIDs to treat his left shoulder injury, Dr. R stated that NSAID use could have side effects such as gastric disease, high blood pressure, and cardiovascular disease. See June 2014 medical treatment record, p. 19. In March 2010, a pharmacist, Dr. A.S., opined that the Ibuprofen that the Veteran has taken since 1972 has likely been a significant contributor to his high blood pressure. Citing medical sources, Dr. A.S. explained that Ibuprofen has been shown to have significant association between frequency of use and hypertension. Dr. A.S. stated that this effect is thought to be due to inhibition of vasodilatory prostaglandins, increase in renal sodium reabsorption, and impairment of endothelial function by Ibuprofen and other NSAIDs. Dr. A.S. noted that the Veteran continues to take Ibuprofen because he has not been presented with an alternative that works well for him. Dr. A.S. further opined that the Veteran suffers from GERD as an unfortunate result of years of exposure to Ibuprofen. Citing medical sources, Dr. A.S. explained that 10 to 20 percent of patients have dyspeptic symptoms during NSAID therapy, noting that Ibuprofen carries a "black box" warning of serious gastrointestinal events. Dr. A.S. further noted that the Veteran has been taking Omeprazole for the dyspepsia which has been induced by the Veteran's chronic exposure to Ibuprofen. See May 2014 medical treatment record, p. 4 In March 2010, Dr. R stated that the Veteran's daily doses of Ibuprofen for his service-connect shoulder disability contribute to acid reflux and hypertension. See March 2010 third party correspondence. In April 2014, Dr. M stated that the Veteran's reflux and blood pressure issues were getting worse and were related to daily, long- term, high dose NSAID use. See June 2014 medical treatment records, p. 29. In May 2014, Dr. S stated that NSAIDs have been found to be potential risk factors for erosive esophagitis, but not for GERD, or for hiatal hernia. However, Dr. S noted that NSAIDs are known to cause dyspepsia, which may be sometimes difficult to differentiate from reflux symptoms. Dr. S noted that treatment with proton pump inhibitors is efficacious in treating GERD symptoms. Dr. S stated that the Veteran's request to his have his prescription for proton pump inhibitors be considered service-connected would appear justifiable if the Veteran's abdominal symptoms are associated with his intake of NSAIDs for his chronic left shoulder pain. See June 2014 medical treatment record, p. 1. In May 2014, Dr. M stated that the Veteran's NSAIDs exacerbate his gastrointestinal issues and have likely contributed to the severity of his GERD symptoms. Dr. M also stated that NSAIDs likely contributed to the severity of his hypertension symptoms, noting that NSAIDs may have increased the Veteran's blood pressure by 5 to 10 points. Additionally, the examiner stated that NSAIDs may also contribute to the Veteran's difficulty in obtaining adequate blood pressure control. See June 2014 medical treatment records, p. 28. In May 2014, Dr. O stated that it is possible that the daily use of a NSAID such as Ibuprofen may contribute to GERD and hypertension. See June 2014 medical treatment records, p. 18. In May 2014, the Veteran's gastroenterologist, Dr. E, stated that he had known the Veteran for over a decade. Dr. E stated that the Veteran suffers from hypertension and acid reflux, which are known to be exacerbated by regular doses of Ibuprofen. Dr. E stated that the hypertension and acid reflux themselves require treatment. Dr. E stated that unless the Veteran can get off of Ibuprofen, the Veteran will require additional treatment for his GERD and hypertension. See June 2014 medical treatment records, p. 20. In July 2014, Dr. O opined that the Veteran's use of anti-inflammatory drugs for his shoulder injury caused GERD and increased blood pressure. Dr. O noted that the Veteran has had to take several medications to control both his GERD and hypertension. Dr. O further opined that it was highly likely that the Veteran's anti-inflammatory medications at least contributed to his GERD and hypertension. See July 2014 VA examination letter, p. 1. Thus, there are current diagnoses of GERD and hypertension, which the medical evidence of record has related to the Veteran's service-connected left shoulder. Accordingly, although the May 2014 VA examiner did not find a link between the Veteran's GERD and hypertension and his service-connected left shoulder, the remainder of the evidence of record shows a diagnosis of GERD and hypertension related to NSAIDS used to treat the Veteran's service-connected left shoulder disability. The number of positive medical nexus opinions of varying detail over several years from several different medical professionals has considerable probative value to the Board. However, the pharmacist, Dr. A.S.'s, substantive and detailed supporting rationale for her positive medical nexus opinion is of the greatest probative value to the Board. Thus, at the very least the evidence for and against the claim is in relative equipoise, and the third Wallin element has been satisfied. Service connection for GERD and hypertension is granted as secondary to medications used to treat the Veteran's service-connected left shoulder disability. ORDER Entitlement to service connection for GERD is granted. Entitlement to service connection for hypertension is granted. ____________________________________________ DONNIE R. HACHEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs