Citation Nr: 20054582 Decision Date: 08/18/20 Archive Date: 08/18/20 DOCKET NO. 08-38 447 DATE: August 18, 2020 ORDER Entitlement to compensation pursuant to 38 U.S.C. § 1151 for pancreatic disability other than brittle diabetes is denied. FINDING OF FACT The Veteran did not incur an additional disability, to include a pancreatic condition, due to VA hospital care or medical treatment. CONCLUSION OF LAW The criteria under the provisions of 38 U.S.C. § 1151 for compensation for a pancreatic disability are not met. 38 U.S.C. § 1151; 38 C.F.R. §§ 3.102, 3.361, 17.32. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from June 1982 to June 1988. In October 2018, the Board remanded the case for further development, which has been completed. Stegall v. West, 11 Vet. App. 268, 271 (1998). In July 2012, the Veteran testified at a Board hearing. The transcript is of record. 1. Entitlement to compensation pursuant to 38 U.S.C. § 1151 for pancreatic disability other than brittle diabetes The Veteran contends she is entitled to compensation pursuant to 38 U.S.C. § 1151 for a pancreatic disability that occurred due to a reaction to Dilantin resulting in the need for medication to replace digestive enzymes. A veteran disabled as a result of VA medical treatment may receive compensation for a qualifying additional disability in the same manner as if such additional disability were service connected. 38 U.S.C. § 1151. An additional disability is a qualifying disability if: (1) it was not the result of the veteran's willful misconduct; (2) the disability was caused by VA hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by the VA; and, (3) the proximate cause of the disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA in furnishing the hospital care, medical or surgical treatment, or examination, or the proximate cause of the disability was an event not reasonably foreseeable. 38 U.S.C. § 1151. To determine whether a Veteran has an additional disability, VA compares the Veteran's condition immediately before the beginning of hospital care, medical or surgical treatment upon which the claim is based to the Veteran's condition after the care, treatment, examination, or services has stopped. 38 C.F.R. § 3.361 (b). In August 2001, the Veteran had a reaction to Dilantin and was admitted to the hospital with hypersensitivity vasculitis, elevated liver enzymes, eosinophilia and worsened diabetes. She also had an acute onset of abdominal pain of unclear etiology with the examiner noting the manner of her discomfort was suggestive of a retroperitoneal process such as pancreatitis. In November 2001, Dr. J. Brown stated that he was treating the Veteran for an adverse reaction to dilantin that occurred at the VA medical center, reporting a complex case of hypereosinophilia and abnormalities of the liver enzymes. In June 2002 an abdominal ultrasound revealed an unremarkable pancreas. Approximately three years later, the Veteran was diagnosed with acute pancreatitis in August 2005; however, a CT scan that same month revealed a normal pancreas. She had another unremarkable CT scan with IV contrast of the pancreas in July 2016. A treatment record from June 2018 noted that the Veteran had a remote history of pancreatitis caused by phenytoin in 2001 with no recurrence since it was discontinued. In March 2013, after review of the file Dr. M. opined that the references to a pancreatic disorder are inconsistent, obscure and infrequent. He concluded that there is nothing to support a diagnosis of exocrine pancreatic disorder, as there is no laboratory or imaging revealing pancreatic dysfunction. Furthermore, he noted that there are no references to pancreatic damage during the hospitalizations in August and September 2001 for hypersensitivity vasculitis. The bloodwork at the time reported normal amylase and lipase upon admission and the ultrasound revealed a normal pancreas. Dr. M reported that the first reference to a pancreatic disorder was in November 2003 when the treating physician made a diagnosis of pancreatic insufficiency and began Pancrease, an oral pancreatic enzyme replacement. In 2004, the Veteran’s gastrointestinal problems were noted to be stable and by December to be completely resolved with Pancrease. In August 2005, she went to the emergency department and had barely elevated amylase and lipase with a normal CT scan of the pancreas. Dr. M noted that the July 2007 prescription list showed irregular filling of Creon and the medication profile from January 2010 through December 2011 revealed no pancreatic medications. In October 2016 the Veteran attended a VA examination and reported that prior to her allergic reaction in August 2001 she did not have a history of pancreatitis. The examiner reported that continuous medication is required for control of the Veteran’s gallbladder or pancreas and she had symptoms consisting of moderately severe abdominal pain with attacks of eight or more in the past 12 months, citing to her subjective comments in the medical history. The examination report noted negative CT scan results from July 2016 and laboratory testing from April 2016 revealing lipase at 55, within normal limits. The examiner concluded that while the Veteran has multiple subjective gastrointestinal symptoms, there is no objective evidence of remote or current pancreatitis based on the laboratory results. The examiner opined that it is more likely than not that the Veteran's hiatal hernia, esophagitis, and chronic constipation are not related to her pancreas condition as the available medical records do not support an unequivocal diagnosis of pancreatic exocrine dysfunction. In July 2019 an addendum opinion was obtained to clarify the conflicting comments in the October 2016 opinion regarding the presence of a pancreatic condition. The examiner reviewed the record to include the prior medical opinions and opined that it is less likely as not that the Veteran's reaction to Dilantin caused or aggravated any pancreatic disability other than diabetes as there are no medical records documenting a chronic pancreatic disability other than diabetes and no evidence of pancreatitis as a reaction to Dilantin. The examiner explained that the 2001 reaction to Dilantin resulted in elevated liver enzymes, not elevated pancreatic enzymes, and there was no evidence of any pancreatic abnormalities on the CT imaging conducted in 2002, 2005, or 2016. The acute pancreatitis diagnosed in 2005 based on mildly elevated pancreatic enzymes was not related temporally to the Dilantin hypersensitivity vasculitis and did not evolve into a chronic pancreatitis condition. Rather, the Veteran's abdominal complaints since 2005 are compatible with esophageal dysmotility and GERD. The examiner noted that while pancreatitis was referenced in August 2001 during a gastroenterology consultation, this was listed as a differential diagnosis that was never confirmed. Furthermore, hospital records from just a few days later did not report pancreatitis. The examiner reported the medical evidence establishes an episode of acute pancreatitis in 2005 but there is no apparent sequelae. As such, the objective evidence does not support a diagnosis of exocrine pancreatic dysfunction requiring pancreatic enzyme replacement; thus, the need for a pancreatic enzyme replacement is unsupported. Additionally, in response to the October 2016 opinion, the July 2019 examiner again explained that the medical treatment records are silent regarding any current pancreatic complaint or diagnosis. The subjective complaints reported at the 2016 VA examination appear to be related to the Veteran's GERD, gastritis and prior H. pylori infection. Again, the examiner noted that the possible diagnosis of pancreatitis in August 2001 was never confirmed, the subsequent hospital records diagnosed hypersensitivity vasculitis and elevated liver enzymes but did not provide a diagnosis of pancreatitis and the episode of pancreatitis in 2005 was mild and acute with no apparent sequelae. Therefore, the evidence does not indicate an exocrine pancreatic dysfunction requiring pancreatic enzyme replacement. The Board gives significant weight to the opinion of the July 2019 examiner as she provided clear conclusions with supporting data and a reasoned medical explanation that is consistent with the medical records. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Additionally, the Board also finds it persuasive that all three medical opinions of record concluded that the objective medical evidence does not support a diagnosis of pancreatic exocrine dysfunction. While the Veteran took medication during the period at issue for pancreatic enzyme replacement, the evidence does not establish the 2001 reaction to Dilantin resulted in chronic pancreatitis, as the Veteran did not have elevated pancreatic enzymes at the time of the reaction or any pancreatic abnormalities on CT imaging in 2002, 2005, or 2016. The record does contain a diagnosis of pancreatitis from 2005; however, it was acute and did not evolve into a chronic pancreatitis condition. The Board acknowledges the Veteran’s contention that she has an additional pancreatic disability requiring lifetime medication to replace digestive enzymes. However, the Veteran is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of a pancreatic condition. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Accordingly, as there is no additional disability in this case which is due to VA care, the Board must deny the Veteran's claim for compensation under 38 U.S.C. § 1151. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. A. Prinsen 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.