Citation Nr: 20022086 Decision Date: 03/30/20 Archive Date: 03/30/20 DOCKET NO. 16-06 436 DATE: March 30, 2020 REMANDED Entitlement to service connection for an esophageal disorder, to include gastroesophageal reflux disease (GERD), Barrett’s esophagus, and residuals of esophageal cancer, to include as due to a qualifying chronic disability pursuant to 38 C.F.R. § 3.317 and/or as secondary to medications taken for service-connected right knee disability, is remanded. Entitlement to service connection for right hand tremors, to include as due to a qualifying chronic disability pursuant to 38 C.F.R. § 3.317, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1988 to June 1992. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. In September 2018, the Veteran and his spouse testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. At such time, he waived Agency of Original Jurisdiction (AOJ) consideration of the evidence associated with the record since the issuance of the February 2016 statement of the case. 38 C.F.R. § 20.1304(c). The undersigned also held the record open for 60 days for the receipt of additional evidence; however, none has been received to date. 1. Entitlement to service connection for an esophageal disorder, to include GERD, Barrett’s esophagus, and residuals of esophageal cancer, to include as due to a qualifying chronic disability pursuant to 38 C.F.R. § 3.317 and/or as secondary to medications taken for service-connected right knee disability. The Veteran claims that his current esophageal disorder, diagnosed as GERD, Barrett’s esophagus, and residuals of esophageal cancer, is directly related to his environmental exposures coincident with his service in Southwest Asia, a result of a qualifying chronic disability pursuant to 38 C.F.R. § 3.317, or caused or aggravated by medications taken for service-connected right knee disability. As an initial matter, the record reflects current diagnoses of GERD, Barrett’s esophagus, and residuals of esophageal cancer. In this regard, an August 2014 Disability Benefits Questionnaire (DBQ) completed by a private physician reflects that the Veteran was diagnosed with esophagal cancer in the setting of Barrett’s esophagus, which was a manifestation of GERD. Further, while his service treatment records are negative for any complaints, treatment, or diagnosis referable to such disorders, his service personnel records reflect that the Veteran served in Southwest Asia in Saudi Arabia from September 1990 to March 1991. Additionally, he is service-connected for a right knee disability, for which he takes nonsteroidal anti-inflammatory drugs (NSAIDs). In a January 2015 DBQ, the Veteran’s private physician stated that the Veteran’s GERD was caused by Gulf War Syndrome and his esophageal cancer is secondary to GERD. However, a rationale for such opinion was not provided and, thus, such is insufficient to establish service connection for the Veteran’s esophageal disorder. Conversely, in January 2015, a VA examiner opined that the Veteran’s GERD and esophageal cancer are clear and specific diagnoses, but were less likely than not incurred in or caused by his service in Southwest Asia or a specific exposure event therein. Additionally, in January 2016, a different VA examiner found that the Veteran did not have a diagnosed illness for which no etiology was established and he did not have any signs and/or symptoms that may represent an undiagnosed illness or a medically unexplained chronic multisymptom illness. She further opined that it was less likely than not that the Veteran’s GERD is etiologically related to his Gulf War service, to include dust storms, pills given or nerve gas attacks, and/or exposure to chemical warfare agents or toxins, as the relevant medical literature published by the Institute of Medicine, which is entitled “Gulf War and Health: Volume 8: Update of Health Effects of Serving in the Gulf War,” revealed no increased risk of GERD was found to be associated with service in the Gulf War. Further, as such disorder is a specific diagnosis with a known etiology, it is not characterized or recognized as a part of “Gulf War Syndrome.” The examiner further opined that the Veteran’s GERD was less likely than not proximately due to, the result of, or aggravated by prescribed and/or over the counter medications for his right knee disability. In this regard, she acknowledged that, while NSAID use has a well known association with the development of gastritis and peptic ulcer disease due to direct toxicity to the mucosa, such medications do not have a causal connection to GERD. Rather, risk factors for GERD include obesity, smoking, and hiatal hernia, all of which are present in the Veteran’s case. The examiner further observed that NSAIDs have not been shown to have any effect on the mechanisms involved with GERD. Further, the effects that NSAIDs can have on the gastrointestinal system are reversible on cessation of the medication and would not contribute to a permanent worsening outside of the natural progression of the condition. However, while the VA examiners adequately addressed whether the Veteran’s esophageal disorder is a result of a qualifying chronic disability pursuant to 38 C.F.R. § 3.317, or caused or aggravated by medications taken for service-connected right knee disability, they did not adequately address whether such is directly related to his military service. In this regard, while the January 2016 VA examiner opined that it was less likely than not that the Veteran’s GERD is etiologically related to his Gulf War service, to include dust storms, pills given or nerve gas attacks, and/or exposure to chemical warfare agents or toxins, her rationale focused solely on whether such was a qualifying chronic disability, i.e., an undiagnosed illness or a medically unexplained chronic multisymptom illness, known to be associated with service in Southwest Asia. Further, at his September 2018 Board hearing, the Veteran reported experiencing indigestion in service for which he took over the counter medication such as Tums. Therefore, the Board finds that a remand is necessary in order to obtain an addendum opinion addressing whether the Veteran’s esophageal disorder is directly related to his military service. 2. Entitlement to service connection for right hand tremors, to include as due to a qualifying chronic disability pursuant to 38 C.F.R. § 3.317. The Veteran contends that his current right hand tremors are directly related to his environmental exposures coincident with his service in Southwest Asia, or a result of a qualifying chronic disability pursuant to 38 C.F.R. § 3.317. As an initial matter, the record reflects a current diagnoses of right hand tremors. In this regard, a July 2014 DBQ completed by a private physician reflects that the Veteran has a mild tremor affecting the right upper extremity. Further, while his service treatment records are negative for any complaints, treatment, or diagnosis referable to such disorder, his service personnel records reflect that the Veteran served in Southwest Asia in Saudi Arabia from September 1990 to March 1991. In January 2015, a VA examiner opined that the Veteran’s right hand tremors is a clear and specific diagnosis, and was less likely than not incurred in or caused by his service in Southwest Asia or a specific exposure event therein. However, the examiner did not address whether the etiology and/or pathophysiology of such disorder is partially or fully understood, or provide a rationale for his determination that such disorder is unrelated to the Veteran’s service in Southwest Asia. Stewart v. Wilkie, 30 Vet. App. 383 (2018) (the etiology and pathophysiology, partial or conclusive, of a condition warrants discussion in determining the claimed disorder is a medically unexplained chronic multisymptom illness). Therefore, the Board finds that a remand is necessary in order to obtain an addendum opinion addressing the nature and etiology of the Veteran’s right hand tremors. The matters are REMANDED for the following actions: 1. Return the record to the VA examiner who offered the January 2016 opinion concerning the etiology of the Veteran's esophageal disorder. The record and a copy of this Remand must be made available to the examiner. If the January 2016 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a full review of the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's esophageal disorder, diagnosed as GERD, Barrett’s esophagus, and residuals of esophageal cancer, had its onset in, or is otherwise related to, his military service, to include his exposure to environmental toxins in Southwest Asia, to include smoke from oil well fires, dust storms, pills taken for nerve gas attacks, and/or chemical warfare agents or toxins? In offering such opinions, the examiner should address the Veteran’s report at his September 2018 Board hearing that he experienced indigestion in service for which he took over the counter medication such as Tums. A rationale for any opinion offered should be provided. 2. Return the record to the VA examiner who offered the January 2015 opinion concerning the etiology of the Veteran’s right hand tremors. The record and a copy of this Remand must be made available to the examiner. If the January 2015 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of the record, the examiner should address the following inquiries: (A) Is it at least as likely as not (i.e., a 50 percent probability or greater) that the Veteran’s right hand tremors, to include any symptoms thereof, abnormal physical findings, and abnormal laboratory test results, represent a “medically unexplained chronic multisymptom illness”? Such is defined as a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. (B) If the Veteran’s right hand tremors are found to have a conclusive pathophysiology or etiology such that they are not a medically unexplained chronic multisymptom illness, is it at least as likely as not (i.e., a 50 percent or greater probability) that such had their onset in, or are otherwise related to, his military service, to include his exposure to environmental toxins in to Southwest Asia, to include smoke from oil well fires, dust storms, pills taken for nerve gas attacks, and/or chemical warfare agents or toxins? A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Breckenridge, Associate 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.