Citation Nr: 21062730 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 17-28 884A DATE: October 12, 2021 REMANDED Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. REASONS FOR REMAND The Veteran had active service from January 1977 to January 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). Initially, in January 2019, the Board remanded the claims for higher evaluations for right shoulder bursitis, lumbosacral strain, allergic rhinitis, and for service connection for GERD for further development. In a subsequent November 2020 Board decision, the claims for entitlement to higher evaluations for right shoulder bursitis, lumbosacral strain, and allergic rhinitis were all denied. As such, those claims are no longer in front of the Board at this time. As for the claim for entitlement to service connection for GERD, the Board remanded the claim to obtain adequate opinions as to its etiology. In particular, an examiner in February 2021 was asked to opine as to whether the Veteran's GERD is related to his reported long-term use of medications during service, and whether these medications at least as likely as not caused or aggravated the Veteran's GERD. The examiner makes clear that there is no indication the actual diagnoses would be related, but in concluding that the medications taken would not cause GERD, the examiner provided inadequate supporting rationale. Specifically, the examiner stated "no objective medical record or reputable medical literature evidence to indicate otherwise was found" but in so stating, the examiner failed to consider the medical literature the Veteran cited to in his August 2011 statement. Further, the examiner opined that "if prescribed medication(s) which occurred 1977-96 (to include but not limited to tetracycline bid for acne) caused the Veteran's GERD then his GERD would have manifested at the time he ingested such medications but no objective medical record evidence to indicate such was found" and that there was no diagnosis for GERD in service. This again fails to consider not only the Veteran's statements, but also the medical evidence from his service treatment records (STRs). Specifically, in an August 2011 statement, the Veteran pointed to STRs showing that he was treated for GERD while in service. For instance, that he was diagnosed with dyspepsia in 1993 and that he was treated for GERD with Mylanta and Tagamet. A review of his STRs correlates with his statement that he had stomach and abdominal pain and diarrhea in 1978 and 1989 with gastroenteritis, and in 1993, he had a diagnosis for dyspepsia and nausea and was prescribed Nexium. The Board notes that the examiner only considered the reports of abdominal pain and gastroenteritis from December 1989 or gastroenteritis from July 1978, but the examiner does not consider the 1993 reports of ongoing treatment and complaints. The Veteran also cited to medical literature as to tetracycline use being known to cause GERD, while, as noted above, the examiner opined there is no medical literature of such. The 2021 opinion also failed to consider the 2017 examiner's opinion that "tetracycline can have side effects of stomach symptoms such as GERD, diarrhea, nausea, or loss of appetite while taking." Further, the 2021 examiner opined there was no objective evidence of the Veteran being treated for GERD post-service, and this again is inaccurate. For example, an endoscopy in January 2005 indicated hiatal hernia and esophagitis. An endoscopy in March 2008 showed a hiatal hernia, and 2008 private medical records indicate he was taking Nexium for reflux. Ongoing medical records show he is also prescribed medication for his reflux. Although the examiner cited to the most recent VA medical records current problem list which did not include GERD as part of the rationale for no post-service ongoing treatment, this fails to consider the prescribed medication list from that same date which clearly notes the Veteran is prescribed Omeprazole and that he takes it daily. Finally, there was no opinion as to whether the tetracycline and other antibiotics as described throughout the Veteran's 20 years of service aggravated the GERD symptoms as he first had symptoms from 1978 and 1989 and then again in 1993. See July 2020 statement from the Veran listing 33 prescribed medications between 1977 and 1996. On remand, an addendum opinion should be obtained. The matters are REMANDED for the following action: Return the claim to the 2021 examiner and request an addendum opinion, or if that examiner is not available from another examiner, to determine the nature and etiology of the Veteran's GERD. The evidentiary record, including a copy of this remand, must be made available to and be reviewed by the reviewing examiner, and the examiner is asked to note the reasons for why the 2021 opinion is not adequate. It is up to the discretion of the reviewing examiner as to whether a new examination is necessary to provide an adequate opinion. After the record review and examination of the Veteran, if deemed necessary, the reviewing examiner is asked to respond to the following inquiries: a.) Is it at least as likely as not that the Veteran's GERD was CAUSED by the acne medication and other antibiotics he was prescribed which occurred 1977-1996 (to include but not limited to tetracycline)? b.) Is it at least as likely as not that the Veteran's GERD was AGGRAVATED by the acne medication and other antibiotics he was prescribed which occurred 1977-1996 (to include but not limited to tetracycline)? In rendering this opinion, the examiner should consider the Veteran's in-service complaints of stomach pain and his diagnosis of dyspepsia in 1993 AFTER the initial 1978 and 1989 report of gastroenteritis. Further, the Veteran's private medical records indicate he has been prescribed Nexium for his reflux since service and that he underwent multiple endoscopies, and a rationale stating there is no post service medical record evidence to indicate treatment for chronic/ongoing GERD condition/pathology is inaccurate. The examiner must also consider the 2017 VA examiner's opinion as to medical literature and tetracycline having side effects. The examiner is also advised that the Veteran is competent to report his symptoms and history, to include the Veteran's August 2011 and July 2020 statements which point to his service medical records and reports of GERD/GERD symptoms and the antibiotics he was prescribed throughout his time on active duty. Those antibiotics and medications MUST be considered as part of the rationale. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the reviewing clinician must provide a complete explanation for why an opinion cannot be rendered. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G.Hoy, 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.