Citation Nr: 21005231 Decision Date: 01/29/21 Archive Date: 01/29/21 DOCKET NO. 14-33 871 DATE: January 29, 2021 ORDER Entitlement to an evaluation of 40 percent for post gastrectomy syndrome is granted. FINDING OF FACT The Veteran’s post gastrectomy syndrome is manifested by symptoms of moderate epigastric distress with diarrhea and fatigue. CONCLUSION OF LAW The criteria for entitlement to an evaluation in excess of 40 percent for post gastrectomy syndrome have been met. 38 U.S.C. §§ 1155 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7308 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Navy from June 1954 to September 1972. This matter comes before the Board of Veterans’ Appeals on appeal from an April 2013 rating decision of the Regional Office (RO). In April 2018, the Veteran testified before the undersigned Veterans Law Judge at a videoconference Board hearing. In July 2018, the Board remanded the Veteran’s claim for further development. Such development has been completed, and this matter is now returned to the Board for decision. Shortly thereafter, a July 2018 Board decision was issued to correct a typographical error in the Board remand directive. Entitlement to an evaluation in excess of 20 percent for post gastrectomy syndrome The Veteran’s post gastrectomy syndrome is currently assigned a 20 percent disability rating under Diagnostic Code 7308, effective December 27, 2012 (and noncompensable prior to). The Veteran seeks an increased rating. See Claim, December 2012. Diagnostic Code 7308, postgastrectomy syndromes, provides a 60 percent rating for severe; associated with nausea, sweating, circulatory disturbance after meals, diarrhea, hypoglycemic symptoms, and weight loss with malnutrition and anemia. A 40 percent rating is provided for moderate; less frequent episodes of epigastric disorders with characteristic mild circulatory symptoms after meals but with diarrhea and weight loss. A 20 percent rating is provided for mild; infrequent episodes of epigastric distress with characteristic mild circulatory symptoms or continuous mild manifestations. See 38 C.F.R. § 4.114 (2019). A February 2013 VA examination report shows the examiner diagnosed “status post gastrectomy” and melena, but not post gastrectomy syndrome. See Report at p.45 of 60. The examiner noted the Veteran experienced occasional symptoms of blood in stool and melena (albeit the Board notes the Veteran subsequently underwent a polypectomy in 2014 after reports of bloody stools). The examiner also noted symptoms of anemia. The examiner noted the Veteran experiences transient melena three times per year, of one day duration. The examiner noted “no” as to whether the Veteran has post gastrectomy syndrome. The examiner noted an upper endoscopy showed no signs of bleeding. The examiner opined that the Veteran’s status post gastrectomy and melena do not affect the Veteran’s ability to work. An October 2019 VA examination report shows the examiner noted a history of a duodenal ulcer, status post vagotomy and gastrectomy. The examiner diagnosed post vagotomy diarrhea, as well as an incisional hernia. The examiner noted that the Veteran underwent surgical treatment in 1970, and that his symptoms of dumping syndrome resolved 30 years ago. The Veteran reported experiencing symptoms of diarrhea, with three to five loose to watery stools per day. The examiner noted the Veteran does not have symptoms of weight loss or interference with nutrition. The examiner opined that the Veteran’s surgical residuals do not affect his ability to work. In a November 2020 addendum, the examiner noted that the Veteran’s reported symptom of diarrhea is attributable to his post gastrectomy syndrome, but that he did not have the symptoms (he reported at the Board hearing) of circulatory problems, including numbness and tingling, weakness and fatigue, sweating, tachycardia, shaking, headaches, or blurred vision due to the post gastrectomy. Regarding reported weight loss, the examiner noted the Veteran’s weight had been stable for three years. The Board has also reviewed all of the Veteran’s treatment records from the period on appeal. A June 2013 VA gastroenterology record shows the Veteran had a hospitalization in December 2012 for gastric ulcers, but a follow up small bowel follow through (SBFT) showed no lesions. He reported diarrhea four to eight times per day. His weight was noted as stable, and that his iron stores had been repleted and he could do a trial of discontinuing iron supplementation. See CAPRI, received October 2013 at p.9. A January 2015 VA gastroenterology record shows he reported diarrhea for 40 years, with four to eight watery bowel movements per day. He reported he was no longer taking iron supplements since 2013, but would get fatigued if his counts are low. He denied weight loss. See CAPRI, received November 2015 at p.183. A June 2015 VA gastroenterology record shows the Veteran was experiencing chronic diarrhea and normocytic anemia. See CAPRI, received November 2015 at p.124. The Board acknowledges that at the Board hearing, the Veteran testified that he has symptoms due to his post gastrectomy of circulatory problems, weight loss, weakness, sweating, tachycardia, shaking, headaches, and blurred vision. However, as noted above, the November 2020 VA medical opinion shows the VA examiner opined that the Veteran does not have these symptoms due to his post gastrectomy. Furthermore, several treatment records show the Veteran denied symptoms such as unintentional weight loss or headaches. See, e.g., CAPRI, received November 2019 at p.79, November 2015 at p.124 and 821. In fact, a January 2016 record shows the Veteran reported intentional weight loss due to a diet. See CAPRI, received June 2017 at p.3. Also, the VA treatment records show he had PT/OT for weakness in his legs due to diagnosed diabetic neuropathy. See CAPRI, received March 2018 at p.5-6. Regarding blurred vision, VA optometry records show he has reported fuzzy distance vision, but that he was diagnosed with dermatochalasis OU, neovascularization (NV), and refractive error OU, and it is shown that he underwent cataract surgery in 2014. See CAPRI, received November 2015 at p.94 of 239. A November 2019 private cardiology record shows the Veteran had symptoms of syncope and sinus bradycardia, not tachycardia, which was appears to have been attributed to the Veteran’s cardiac condition. See Records, received November 2019 at p.2 of 5. The Board adds that during the period on appeal, the Veteran has had a significant medical history of coronary artery disease with stent replacement in 2012, as well as chronic hepatitis C, cirrhosis of secondary to hepatitis C, cholangiocarcinoma, treated with a cholangiotomy in November 2015, right carotid artery stenosis, and sleep apnea. See Records, received June 2017 at p.22 of 58, received June 2017 at p.10, 12, and 22 of 118, and received February 2013 at p.11, 17, and 21 of 26. An October 2015 nursing note shows the Veteran was educated as to the symptoms of chronic hypertension, including headache, blurred vision, and weakness. See CAPRI, received November 2015 at p.72 and 127. Symptoms of shaking and sweating are not shown in the treatment records. Having reviewed all the evidence, the Board finds that because the Veteran experiences diarrhea four to eight times a day, and based on his history of anemia, entitlement to the next higher 40 percent rating for the Veteran’s post gastrectomy syndrome is warranted. The present 20 percent rating contemplates “mild” symptoms of epigastric distress, but no diarrhea. The next higher 40 percent rating criteria contemplate, among other things, “moderate” symptoms of epigastric distress, as well as diarrhea. Here, the Veteran has reported diarrhea for 40 years, consistently reported as four to eight episodes per day. He also reports experiencing fatigue when his iron is low since he stopped iron supplementation in 2013. While the Board acknowledges that the 40 percent criteria also contemplate weight loss, and the most recent VA examination report shows the examiner noted the Veteran has no unintentional weight loss, the Board nevertheless finds that the overall disability picture, with diarrhea four to eight times per day is sufficient to bring the Veteran’s overall disability picture to more nearly approximate the higher 40 percent rating criteria. The Board emphasizes again that diarrhea is contemplated by the 40 percent criteria, but not the present 20 percent rating. The Board further finds that entitlement to the maximum 60 percent rating under Diagnostic Code 7308 is clearly not shown, as the Veteran is not shown by any of his treatment records, including several gastroenterology records, to experience symptoms such as nausea, sweating, circulatory disturbance after meals, hypoglycemic symptoms, and weight loss with malnutrition and anemia due to his post gastrectomy. This is not a case involving a lack of contemporaneous records of treatment. Rather, there are several treatment records from the period on appeal, including records of being followed by VA gastroenterology. There is insufficient confirming evidence of this level of symptomatology due to the Veteran’s post gastrectomy syndrome. His anemia has already been considered in awarding the higher 40 percent rating herein. Therefore, in summary, the Board concludes that entitlement to a 40 percent rating for post gastrectomy syndrome is warranted, but no higher. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Juliano, 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.