Citation Nr: 20005481 Decision Date: 01/23/20 Archive Date: 01/22/20 DOCKET NO. 10-36 432 DATE: January 23, 2020 ORDER Service connection for an upper-gastrointestinal (GI) disorder is denied. REMANDED Service connection for deep vein thrombosis with chronic venous stasis, left lower extremity, is remanded. FINDING OF FACT The Veteran’s upper-GI disorder was not caused or aggravated by his service-connected disabilities, including the medication required for such. CONCLUSION OF LAW The criteria for service connection for an upper-GI disorder have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from September 1981 to September 1982. The case is on appeal from a September 2008 rating decision. In a May 2016 decision, the Board denied the claim for service connection for an upper-GI disorder. The Veteran appealed the Board decision to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a December 2016 joint motion for remand (JMR), the Court issued a January 2017 order that vacated the Board’s May 2016 decision and remanded the claim to the Board for further development. Thereafter, the claim for service connection for an upper-GI disorder came before the Board and was remanded several times, most recently in February 2018, for further development. 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, his representative 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). Legal Criteria 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. § 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: “(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.” Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. Analysis The Veteran contends that his upper-GI disorder was caused or aggravated by his service-connected disabilities, to specifically include the medication required for those disabilities. The Veteran’s service-connected disabilities include both knees, residuals of a pulmonary embolism and deep vein thrombosis of the right lower extremity. The first reference to GI treatment is found in the record in a June 2005 VA treatment record, in which the Veteran was prescribed the acid reducing medication omeprazole. A February 2006 VA treatment record indicated the Veteran had an esophagogastroduodenoscopy (EGD) performed, which showed patchy esophagitis at the lower third of his esophagus. The record noted the Veteran had been taking the acid reducing medication Nexium (esomeprazole) and had no change in his symptoms. The Veteran was found to have dysphagia and was diagnosed with esophagitis. The Board notes additional VA treatment records show the Veteran was unable to take non-steroidal anti-inflammatory drugs (NSAIDs) for his lower extremity pain, as early as May 2005. Moreover, several May 2005 VA treatment records show he could not take NSAID medication for pain because he was taking coumadin. A January 2008 VA treatment record also showed the Veteran was not taking NSAID medication due to coumadin, as well as March 2015 and July 2019 VA records. The Veteran was afforded a September 2008 VA examination in which the examiner indicated the Veteran had nonservice-connected injuries and resultant arthritis which necessitated NSAID or narcotic medication usage. The examiner noted a motor vehicle accident in 1999 which resulted in severe compression of his cervical spine and bulging discs of his lumbar spine. The examiner noted the Veteran injured his right wrist playing football in 1990, and in April 2005, had an excision of the right second carpometacarpal joint boss and fusion of the right second carpometacarpal joint with autogenous distal radius bone graft. The examiner also reported an intervening twisting injury to the left knee in August 2007 when he twisted the knee and fell down stairs. The Veteran reported to the examiner that one year prior, he began to have chest pain and went to VA for treatment. Cardiac causes were ruled out and he had a barium swallow, which showed marked gastroesophageal reflux. The examiner diagnosed the Veteran with gastroparesis and gastroesophageal reflux disease (GERD). The examiner opined the Veteran’s stomach disorders are not related to the medications required for his service-connected disabilities and it would be resorting to mere speculation to state they were. An addendum opinion was provided by the examiner later in September 2008. She indicated the Veteran’s esophageal problems are anatomic, not functional, and not secondary to his pain medications prescribed for multiple orthopedic disabilities, most of which are not service connected. The Veteran submitted a September 2009 notice of disagreement (NOD) in which he again asserted his medications for his service-connected disabilities led to his GI disorders. He indicated he was taking 16 pills per day at that time and disagreed with the conclusions from the prior VA examiner. Additionally, an opinion in support was submitted in September 2009 from the Veteran’s sister, a registered nurse. She indicated the Veteran injured his knees many years prior during service and in the years since his injuries, he had experienced deep vein thrombosis and a pulmonary embolism. She reported as a result of the many medications, including the use of NSAID medication, he has developed Barrett’s esophagus, a stomach disorder manifested by extreme and repeated chest pain. She stated the Veteran was taking maximum doses of proton pump inhibitors and acid reducing medication, and “his health has certainly been compromised by these events precipitated by his initial knee injury.” As noted above, the Board denied the claim in May 2016. The Court then vacated the decision in the January 2017 order, pursuant to the December 2016 JMR. The Court indicated remand was necessary to obtain clarification regarding the September 2008 VA examination report, including whether gastroparesis was caused or worsened by the medications taken for the Veteran’s service-connected conditions, and with specific instructions to address secondary aggravation. The claim was remanded by the Board in March 2017 for a VA opinion which was provided in April 2017. The examiner stated it is less likely as not that medications taken for the service-connected disabilities permanently worsened the Veteran’s upper-GI disorder beyond the natural progress of the disease. As rationale, the examiner stated that the Veteran is no longer on NSAIDs for arthralgias since October 2015, the last EGD in November 2014 showed chronic inflammation but without Barrett’s esophagitis, and the Veteran’s GERD symptoms were described as well controlled since 2015, without further complaints of worsening of this condition. The claim came before the Board again and was most recently remanded in February 2018 for another VA opinion. The Veteran was afforded an April 2018 VA examination in which the examiner determined the Veteran’s upper-GI disorder was not caused or aggravated by the medication for his service-connected disabilities. She indicated the Veteran’s Barrett’s esophagitis resolved based on the November 2014 EGD. She stated he has continued diagnoses of GERD and gastroparesis. She noted the Veteran takes the medications ranitidine and lansoprazole, as well as TUMS OTC prn. The Veteran also reported taking ibuprofen 800 mg every 6-8 hours, for 1-2 years. The examiner opined the Veteran is no longer on NSAIDs for arthralgia pain, since 2007. She further noted the last EGD in November 2014 showed chronic inflammation but without Barrett’s esophagitis. She stated there was no evidence of gastritis, duodenitis, peptic ulcer disease or duodenal ulcer disease. She reported the Veteran’s GERD symptoms were described as well-controlled since 2015, without further complaints of worsening or medication changes required. Thus, the examiner concluded there is no objective evidence, including EGD evidence, that the Veteran’s GI disorder was caused or aggravated by his service-connected disabilities, to include any side effects from taking medication required for the conditions. Thereafter, in July 2019, the Veteran submitted medical articles in support of his claim. Such articles noted the risks associated with upper and lower GI bleeding in patients taking NSAIDs, anti-inflammatory drugs, antiplatelet agents or anticoagulants. The articles discuss how anticoagulants, low-dose aspirin, NSAIDs, and other non-aspirin drugs are associated with an increased risk of upper and lower GI bleeding, and how the use of anticoagulants appears to be a strong risk factor for GI bleeding. In consideration of the evidence, the Board determines the Veteran’s upper-GI disorder is not related to his service-connected disabilities, including the required medication. The Board finds the Veteran’s GI condition was not caused by such medication and did not increase in severity beyond the natural progress of the disorder due to the medication. In reaching this conclusion, the Board accords the most probative weight to the April 2018 VA examination report. The Veteran’s claim has a lengthy appeal history and the Board determines the April 2018 VA examiner’s opinion to be the most persuasive evidence of record. Her conclusions were clear and unequivocal in finding the Veteran’s upper-GI disorder was not caused or aggravated by the medication required for his service-connected disabilities. Her opinion was accurate and contained well-reasoned explanations with references to the objective medical evidence of record, which support her conclusions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (“[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). The Board acknowledges the opinion in support received in September 2009 from D.R., a registered nurse. She indicated as a result of the many medications the Veteran takes, including the use of NSAIDs, he developed Barrett’s esophagus, a stomach disorder manifested by extreme and repeated chest pain. She stated the Veteran’s health was compromised by the medication related to his service-connected knee disorders. While this opinion supports the Veteran’s claim, the Board finds the April 2018 medical opinion more persuasive. The September 2009 opinion made no reference to objective medical evidence or testing performed for the Veteran. In contrast, the April 2018 examiner indicated the Veteran’s Barrett’s esophagitis has resolved, as evidenced by the November 2014 EGD. The examiner also significantly opined the Veteran is no longer on NSAIDs for arthralgia pain, since 2007, and the November 2014 EGD suggests no evidence of gastritis, duodenitis, peptic ulcer disease or duodenal ulcer disease. She reported the Veteran’s GERD symptoms were described as well-controlled since 2015 without further complaints of worsening or medication changes required. Additionally, the Board notes the April 2018 VA examiner’s opinion is supported by the record, as the Veteran’s VA treatment records show that he stopped taking NSAIDs due to his use of coumadin. As noted above, May 2005 VA treatment records show he could not take NSAID medication for pain because he was taking coumadin. Further, January 2008, March 2015 and July 2019 VA records also show the Veteran was not taking NSAID medication due to coumadin use. The Board acknowledges the medical articles submitted by the Veteran in July 2019 which address the risks associated with upper GI bleeding in patients taking NSAIDs, anti-inflammatory drugs, antiplatelet agents or anticoagulants. However, the medical articles are not specific to the Veteran and the facts of his case, including the medications he takes, and were not accompanied by a medical opinion in support. As noted, the evidence shows the Veteran has not been regularly taking NSAIDs for pain related to his service-connected disabilities since as early as 2005. Thus, the Board finds the medical articles submitted are not specific to the Veteran’s case and are therefore insufficient to establish a relationship between the Veteran’s service-connected medication and his upper-GI disorder. In sum, based on the most probative evidence of record, the Board finds that the Veteran’s upper-GI disorder was not caused or aggravated by his service-connected disabilities, including the medication required for such. The preponderance of the evidence is against the claim, and thus, service connection for an upper-GI disorder is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Although the Board is remanding a claim for additional development, remand is not necessary for the claim decided herein, as there is no reasonable possibility that further assistance would substantiate the claim. See 38 C.F.R. § 3.159(d). REASONS FOR REMAND The Veteran’s claim for service connection for deep vein thrombosis with chronic venous stasis, left lower extremity, was denied in the March 2018 rating decision. Thereafter, the Veteran submitted an August 2018 NOD. When an NOD is submitted in response to a rating decision, a statement of the case (SOC) is necessary. Thus, the Board will remand the issue for an SOC. See 38 C.F.R. § 19.9(c); Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The matter is REMANDED for the following action: Unless the benefit sought is granted in full, issue an SOC concerning the issue of service connection for deep vein thrombosis with chronic venous stasis, left lower extremity. This issue should only be returned to the Board if a timely substantive appeal is filed. JEREMY J. OLSEN Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Isaacs, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.