Citation Nr: 21066199 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 19-33 381 DATE: October 28, 2021 REMANDED Entitlement to service connection for gastritis is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army during peacetime, from September 1975 to August 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2019 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for gastritis. The Veteran testified at a hearing before the undersigned Veterans Law Judge in May 2020. A transcript of this hearing is associated with the record. 1. Entitlement to service connection for gastritis is remanded. The Veteran's service treatment records indicate the Veteran was treated for acute gastritis in May 1976. After treatment he was returned to duty with a notation that he was medically fit to remain on active duty. His medical instructions were to take oral medication daily "until gone." The Veteran then had an acute episode of gastroenteritis (i.e., stomach flu) about two weeks later, with vomiting and diarrhea. The Veteran was then scheduled for an upper gastrointestinal (UGI) series, which was found to be normal in July 1976. The Veteran testified he initiated care with the VA in 2009. None of the Veteran's VA medical records refer to a history or diagnosis of gastritis, nor to any complaints of stomach or gastrointestinal issues. However, the Veteran has an active prescription for famotidine 20 mg, an antacid medication, with instructions to take it once daily "for stomach acid." This active prescription through the VA indicates the Veteran has stomach acid complaints. The medical records of the Veteran's private endocrinologist, Dr. D.N., also mention "gastritis" on the Veteran's problem list. The first mention of gastritis in Dr. D.N.'s notes was in April 2015, where it was included on the "Active Problem List" along with "diarrhea," the latter of which was also listed under the "Assessments" section which dealt with the Veteran's current conditions. It is unclear whether the Veteran has a current diagnosis of gastritis or another gastrointestinal disability. At the May 2020 hearing, the Veteran testified he had three incidents of stomach pain or chest pain in service, including one incident where he thought he was having a heart attack. He testified he was told the doctors thought he had ulcers but testing showed he did not. He testified that four months after separation from military service, he experienced gallbladder issues necessitating a cholecystectomy, had two post-surgical hernias, and that his stomach "blew up." He testified he currently experiences stomach pain and constipation, and that he has experienced stomach issues since separation, which were and are "the same" as what he experienced in service. When asked what his condition was like presently, he replied "if my stomach blows up, I still get pain." The Board notes that a VA medical examination has not been obtained in connection with the Veteran's claim for gastritis. VA's duty to assist includes providing a medical examination when it is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but there is: (1) competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of a disability; (2) evidence of an in-service event, injury, or disease (or disease falling under presumptive rules); and (3) the evidence indicates that the current disability or symptoms may be associated with the in-service event. McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). The third prong is a "low threshold" standard. Id. The Veteran's testimony along with the medical evidence of record reflects persistent or recurrent symptoms of a disability. The Board notes that the Veteran is competent to testify regarding symptoms of stomach pain and constipation, which are symptoms readily observable by a lay person. The Board also acknowledges that the Veteran experienced an episode of gastritis during his period of active service and an episode of gastroenteritis, which constitute evidence of in-service events or diseases. And, although it is unclear whether the Veteran has a current diagnosis of gastritis or any other gastrointestinal disability, the evidence indicates his current symptoms may be associated with the in-service event(s). The Veteran has testified under oath that he experiences "the same" symptoms as those experienced in service. Therefore, pursuant to McLendon, a remand for a VA medical examination is necessary to determine the diagnosis and etiology of the Veteran's claimed gastritis. The matters are REMANDED for the following action: 1. Associate with the claims file any outstanding VA treatment records. 2. Schedule the Veteran for a VA medical examination by an appropriate clinician to determine the diagnosis and etiology of any gastrointestinal disability, including gastritis. The claims file must be made available to and reviewed by the examiner. Any indicated studies must be performed. The clinician should provide opinions responsive to the following: (a.) Identify (by diagnosis) any gastrointestinal disability present during the pendency of the appeal. (b.) For any diagnosed gastrointestinal disability, the clinician must opine whether it is at least as likely as not (a 50 percent or greater probability) that the disability is etiologically related to the Veteran's military service. A complete and fully explanatory rationale must be provided for any opinion offered. The examiner is reminded that the Veteran is competent to report the onset and duration of his symptoms as well as his medical history. 3. Thereafter, readjudicate the issue. If the benefits sought on appeal remain denied, the Veteran and his representative should be provided with a supplemental statement of the case. Then, return the case to the Board. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Medley, 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.