Citation Nr: 21061412 Decision Date: 10/04/21 Archive Date: 10/04/21 DOCKET NO. 16-11 469 DATE: October 4, 2021 ORDER Service connection for a stomach condition including gastroesophageal reflux (GERD) and Crohn's disease is denied. FINDING OF FACT The Veteran's GERD did not have its onset during active service and is not otherwise etiologically related to his active service. CONCLUSION OF LAW The criteria for service connection for a stomach condition including gastroesophageal reflux (GERD) and Crohn's disease have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from February 1985 to December 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2014 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In April 2019, the Board denied service connection for a stomach condition including GERD and Crohn's disease. The Veteran appealed the Board's April 2019 decision to the United States Court of Appeals for Veterans Claims (Court). In July 2020, the Court vacated in part and remanded the Board's earlier decision in a Joint Motion for Partial Remand (JMPR) indicated that the denial relied on an inadequate August 2013 medical opinion. In January 2021, the Board remanded this claim for further development Service connection for a stomach condition including gastroesophageal reflux (GERD) and Crohn's disease Generally, service connection will be granted if the evidence demonstrates that a current disability resulted from a disease or injury incurred in active military service. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection requires evidence of a current disability, an in-service incurrence, disease or injury and a causal relationship between the current disability and the in-service incurrence, disease or injury. See Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Service connection may be awarded on a presumptive basis for certain chronic diseases listed in 38 C.F.R. § 3.309(a) that manifest to a degree of 10 percent within 1 year of service separation or during service and then again at a later date. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013). Organic disease of the nervous system and gastric ulcers are considered to be chronic diseases under 38 C.F.R. § 3.309. Evidence of continuity of symptomatology may be sufficient to invoke this presumption if a claimant demonstrates (1) that a condition was "noted" during service; (2) evidence of post service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post service symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (citing Savage v. Gober, 10 Vet. App. 488, 49697 (1997)); see 38 C.F.R. § 3.303(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. See Alemany v. Brown, 9 Vet. App. 518 (1996). In April 2019, the Board held that the Veteran's service treatment records (STRs) showed he was seen for complaints of severe abdominal pain and vomiting in December 1988; he was diagnosed with acute gastroenteritis. He was seen again in December 1988 for complaints of constipation. The STRs also indicate the Veteran was seen in September 1989 for abdominal pain with episodes of nausea and diarrhea with stomach cramps; the diagnosis was probable viral infection, and he was prescribed Kaopectate. The Veteran further submitted records to the claims file which include private treatment reports date from March 1994 through November 2010, showing Veteran received clinical evaluation and treatment for chronic abdominal pain, with diagnoses of GERD, cholecystitis and Crohn's disease. The Veteran maintains that he developed a chronic stomach condition in service and has continued to experience symptoms of a stomach condition, including abdominal pain, nausea and diarrhea. The Board relied on the August 2013 VA examination and the VA examiner's opinion that it is more likely than not that the Veteran's intestinal conditions in service were self-limited episodes of gastroenteritis and the later GI conditions started in the mid-1990s involving his stomach, gallbladder, colon and intestines were a combination/variety of unrelated disorders which seems to be fairly well controlled for several years on diet alone. Subsequently, the Board denied entitlement to service connection. See April 2019 BVA Decision. In July 2020, the Court vacated the Board's April 2019 denial of service connection and stated the August 2013 VA medical opinion was inadequate for rating purposes as the examiner failed to provide an adequate rationale as to why the Veteran's various stomach conditions were not related to his stomach issues in service. See July 2020 CAVC Decision. Pursuant to the Court's July 2020 order and the JMPR findings, the Board remanded the matter for a new examination and medical opinion. See January 2021 BVA Decision. The Veteran was afforded a VA Stomach and Duodenal Conditions examination in April 2021. There was no diagnosis found for a stomach or duodenum condition. The examination results concluded that Veteran reports a history of constipation that leads to abdominal cramps/pain, then nausea occasionally with vomiting; these symptoms are more reflective of a lower GI condition while results were negative for gastric ulcers, and there is no additional evaluation or follow up for gastropathy. The reports of acid reflux and heartburn were also deemed more consistent with esophageal and lower GI symptoms. The VA examiner added that the gastroenteritis the Veteran was diagnosed with during active service was acute only and there have not been records of recurrence of the condition. As there was no diagnosis of gastroenteritis or any other stomach or duodenal condition upon examination, it was less likely than not there is a stomach condition related to the Veteran's military service and a nexus has not been established. See April 2021 C&P Exam. The Veteran was also provided a VA Esophageal Conditions examination in July 2021. The Veteran's GERD diagnosis was reaffirmed, and his esophagitis was noted to be resolved. The Veteran's medical history also noted a colonoscopy from April 2016 noted no evidence of Crohn's disease, Veteran takes Omeprazole as medication to control his GERD and there is no current objective evidence of stomach or intestinal pathology. The VA examiner held that the Veteran was previously diagnosed with "diffuse gastropathy" based on EGD in November 1998 in response to his complaints of abdominal pain beginning in 1996. A subsequent EGD in April 2016 was noted as normal; there is no indication of the presence of any chronic stomach pathology during service. The Veteran current GERD was opined to be less likely than not incurred in or caused by active duty service as the review of the record revealed no evidence of the presence of GERD during service; rather, signs indicative of GERD initially noted in 1996 several years after separation from service. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board considered the Veteran's lay statements asserting a nexus between his stomach conditions and his military service. As a finder of fact, based on a review of the lay and medical evidence, the Board finds that there has not been recurrent gastrointestinal symptoms since service. Further, as a lay person, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex disorder of GERD. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). Further, the etiology of the Veteran's GERD is a medical question involving internal and unseen system processes unobservable by the Veteran. As the record does not reflect that the Veteran has such understanding or ability to relate a stomach condition to his in-service complaints of abdominal pain and diarrhea, any contention regarding the claimed relationship does not have probative value. The Board places great weight upon the July 2021 opinion of the VA examiner, in part, because a competent medical opinion on how GERD is related to in-service complaints of abdominal pain and a finding of gastroenteritis requires expert understanding of anatomy and the largely unseen, unobservable mechanics within the digestive system. For all of the above reasons, the preponderance of the evidence is against a finding that there is a nexus between the Veteran's current GERD and his active service. The Board has considered the benefit of the doubt doctrine when making these findings, but the preponderance of the evidence is against the Veteran's claim for entitlement to service connection. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102, 3.303, 3.307. 3.309. The appeal as to this issue must be denied. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Zarar Ahmed, Attorney Advisor 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.