Citation Nr: 21066889 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 17-11 461 DATE: November 2, 2021 ORDER Entitlement to service connection for a gastrointestinal ("GI") condition is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, his current gastrointestinal ("GI") conditions are proximately due to the 1976 gastric surgery resulting from alcohol abuse as self-medication to control the symptoms of the service-connected PTSD; or otherwise, were aggravated by the alcohol abuse and/or medication used to control the Veteran's service-connected disabilities. CONCLUSION OF LAW The criteria for entitlement to service connection for a gastrointestinal ("GI") condition have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Navy from February 1969 to June 1973. This matter comes before the Board of Veterans' Appeals ("Board") on appeal from a July 2016 rating decision of the Department of Veterans Affairs ("VA") Regional Office ("RO"). The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in November 2020. A transcript of the hearing is associated with the record. The Board remanded the matter in March 2021 for additional development. After completing the development, the RO issued a supplemental statement of the case in August 2021, denying entitlement to service connection for a gastrointestinal ("GI") condition and returned the matter to the Board for appellate consideration. Entitlement to service connection for a gastrointestinal (GI) condition: The Veteran filed a claim for GI conditions, including bacterial overflow into stomach following stomach surgery in 1976 as secondary to the service-connected PTSD and self-medicating it with alcohol, or alternatively directly related to active service. The Veteran has already been granted service connection for post-traumatic stress disorder ("PTSD") that has been recharacterized by RO as "post-traumatic stress disorder and secondary major depressive disorder with history of alcohol dependence-in full sustained remission," which means alcohol dependence has been etiologically linked to the service-connected PTSD, and is considered service-connected for purposes of consideration of secondary service connection for any disabilities caused or aggravated by the past alcohol abuse. At the November 2020 Board hearing, the Veteran asserted that his gastrointestinal conditions are related to his 1976 stomach surgery, which was a result of alcohol abuse that destroyed the lining of his stomach, hence a part of the stomach and eight inches of his small intestines were removed. The Veteran also stated that the doctor told him that his stomach lining was burned and that is why a part of his small intestine was removed. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. Secondary service connection requires: (1) a service-connected disability; (2) a nonservice-connected disability; and (3) evidence that the nonservice-connected disability is either (a) proximately due to or the result of the service-connected disability or (b) aggravated (increased in severity) by the service-connected disability and not due to the natural progress of the nonservice-connected disability. Id. In determining whether service connection is warranted for a disability, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990); 38 C.F.R. § 3.102. Thus, the question for the Board is whether the Veteran has a GI condition that began during service or is at least as likely as not related to an in-service injury, event, or disease; or alternatively proximately due to or the result of alcohol abuse for controlling the symptoms of his service-connected PTSD that resulted in 1976 stomach surgery. The existence of a current GI condition is not in question because in May 2016 disability benefit questionnaire ("DBQ"), the examiner noted the diagnosis of bilroth II due to peptic ulcer disease, acute gastritis, bacterial overgrowth, sulfuric belching, and abdominal pain. Also, in August 2021 DBQ, the examiner noted gastroparesis, cyclic vomiting syndrome, and abdominal pain. As far in-service treatment or diagnosis of a GI condition is concerned, the Veteran was not diagnosed with any of the current GI conditions during his service. Regarding a relationship between a current GI condition and alcohol abuse as secondary to PTSD, a medical opinion was obtained in May 2016, in which the examiner opined that it is less likely than not that the Veteran's PUD (peptic ulcer disease) with partial stomach removal in 1976 were proximately due to or caused by his PTSD with substance abuse. As a rationale, the examiner stated that diverticula occur at points of weakness in the bowel wall where blood vessels penetrate. The development of diverticula is probably multifactorial, involving both increases in intraluminal pressure caused by abnormalities in motility and histologic abnormalities in the bowel wall, which decrease tensile strength. Environmental and lifestyle factors are important risk factors in diverticular disease, diet low in fiber and high in fat and red meat increase likelihood of diverticular disease. Physical activity decreases the risk of diverticular disease, while obesity is associated with an increased risk of diverticular disease. Smoking also increases risk of diverticulitis, as well as several medications such as anti-inflammatory drugs, steroids, and opiates. Gastroparesis is a syndrome of objectively delayed gastric emptying in the absence of a mechanical obstruction and cardinal symptoms of nausea, vomiting, early satiety, bloating, and/or upper abdominal pain, and majority of cases are idiopathic, diabetic, or postsurgical. The examiner further stated that per UpToDate online article entitled "Peptic ulcer disease: Genetic, environmental, and psychological risk factors and pathogenesis," alcohol in high concentrations damages the gastric mucosal barrier to hydrogen ions and is associated with acute gastric mucosal lesions characterized by mucosal hemorrhages. Alcohol also stimulates acid secretion. In addition, contents of alcoholic beverages other than alcohol are also strong stimulants of acid secretion. Despite these acute effects, there is no evidence that alcohol intake causes or exacerbates chronic peptic ulcer disease. Modest alcohol consumption may even promote ulcer healing. The examiner further stated that the Veteran has abdominal pain for which no cause has been found at this time. The Veteran uses NSAID (nonsteroidal anti-inflammatory drugs) and has history of smoking tobacco and was smoking marijuana when seen by gastroenterologist and she recommended no marijuana due to hyperemesis disorder related to Bilroth II procedure. There is no objective medical evidence of a causal relationship of a disease of the stomach/duodenum caused by PTSD with secondary depression and history of substance abuse in full sustained remission when accounting for other potential causes of abdominal pain post Bilroth II, such as NSAID use, chronic opioid use, and the absence of disease on endoscopy, duodenal biopsy, and MRI. It is less likely than not that the Veteran's current abdominal pain is a residual of his peptic ulcer disease and Hx of ETOH abuse. The symptoms of the PUD with partial removal of his stomach were resolved with this surgery. The Board notes that the above medical opinion inadequate because the examiner did not provide opinion on aggravation of a GI condition by alcohol or substance abuse that resulted in 1976 gastric surgery. However, the examiner noted that there can be other causes of current stomach problems post Bilroth II, such as NSAID or chronic opioid use. The Board notes that in November 2020, a VA Gastroenterologist stated that the Veteran's gastrointestinal disorders started in 1976 after Bilroth II surgery, presumably due to excess alcohol intake, which may have caused peptic ulcer disease vs. toxic injury to the gastric mucosa, and the Veteran subsequently suffered from multiple gastric abnormalities. The physician opined that the Veteran's GI problems are greater than 50% related to his 1976 gastric surgery. Since there are conflicting opinions, the Board remanded the matter in March 2021 to obtain a new medical opinion and directed the examiner to provide opinion regarding GI conditions due to 1976 gastric surgery, as secondary to alcohol abuse that is already service-connected, and as secondary to medications used to treat the service-connected disabilities because the Veteran has chronic pain associated with the service-connected cervical spine disability and he takes pain medication. The examiner was also directed to provide opinion on causation as well as aggravation of a GI condition. Consequently, a VA medical opinion was obtained in August 2021, in which the examiner stated that the Veteran had Bilroth 2 surgery for peptic ulcer disease 1976, and thus has post-operative anatomical changes to his stomach, duodenum and jejunum. He has had no recurrent peptic ulcer disease, but had retained gastric contents on upper endoscopy, suggesting gastroparesis as likely as not a post-operative finding. No post-operative anatomic obstruction has been identified. The examiner further stated that the Veteran has been taking PPIs including omeprazole for many years to manage the acid secretion related to his GERD and past peptic ulcer disease and is reported to be stable on this medication. The Veteran also has history of, and current diagnosis of, cyclic vomiting syndrome. Cyclic vomiting syndrome is an idiopathic disorder characterized by recurrent bouts of vomiting with intervening periods of normal or baseline health. The pathogenesis of cyclic vomiting syndrome is unknown. The condition is commonly treated with the migraine medication, sumatriptan, which is reported to control this Veteran's symptoms. The examiner opined that the Veteran's current GERD and gastroparesis are as likely as not (50% or greater probability) are residuals of his prior peptic ulcer disease and Bilroth 2 surgical treatment. His GERD, past peptic ulcer disease and presumed gastroparesis are currently adequately managed with dietary management and PPIs (Omeprazole) as per current VA records. The examiner further opined that the Veteran's cyclic vomiting syndrome is an idiopathic syndrome without identified etiology, as per current medical literature. The Veteran's cyclic vomiting syndrome is being controlled with sumatriptan (a common migraine medication). The examiner also opined that the Veteran's service-connected PTSD less likely than not (less than 50% probability) aggravates his GERD and gastroparesis beyond natural progression. His GERD, past peptic ulcer disease and presumed gastroparesis are related to anatomy, and currently adequately managed with dietary management and PPIs (Omeprazole). The examiner also opined that service-connected PTSD less likely than not (less than 50% probability) aggravates his cyclic vomiting syndrome beyond natural progression, as it is an idiopathic condition, without identified relationship to his cyclic vomiting. In the end the examiner included information and assessments from the previous examinations and VA treatment records. The Board finds the August 2021 VA medical opinion inadequate because the examiner related the Veteran's GI conditions with 1976 gastric surgery, however, the examiner did not opine whether the gastric surgery was caused by the service-connected alcohol abuse. Also, the examiner did not opine whether the medications used by the Veteran to control the symptoms of the service-connected disabilities has any causative or aggravation relationship with his current GI conditions. As far as the records of 1976 gastric surgery is concerned, the Board did not find that in the records associated with the claims file, therefore, in the March 2021 remand, the Board directed the RO to obtain these records. In this regard, the Board notes that the RO requested this information from the Veteran, and in a March 2021 correspondence, the Veteran's representative stated that the Veteran's gastric surgery was done by Dr. Panke at San Bernardine's Hospital in San Bernardino, California in December 1976. The Veteran called the hospital to obtain the records, however, they informed him that the surgical records would have been destroyed after 10 years. As far as other evidence regarding any relationship between alcohol abuse and 1976 gastric surgery is concerned, there are statements from the Veteran indicating that the doctor who performed the surgery informed him that it was due to excessive alcohol intake. During an October 1997 hearing testimony at the Regional Office Center in Wichita, Kansas, the Veteran stated that a part of his stomach was removed in 1976 due to excessive alcohol intake. As noted above, at the November 2020 Board hearing, the Veteran asserted that the 1976 stomach surgery was the result of alcohol abuse that destroyed the lining of his stomach, hence a part of the stomach and eight inches of his small intestines were removed. He also stated that the doctor informed him that his stomach lining was burnt, and this is why a part of his small intestine was removed. In an April 2021 correspondence, the Veteran stated that Dr. Panke, who performed the stomach surgery in 1976, informed him that alcohol abuse led to the gastric surgery. The Board finds the Veteran's reports regarding the doctor's statement credible because he has been consistently reporting the same in the evidence of record. Therefore, the Board finds that there is potential relationship between the excessive alcohol intake and 1976 gastric surgery that resulted in current GI symptoms. In this regard, the Board assigns a great probative value to the VA Gastroenterologist's November 2020 statement, in which the specialist opined that the Veteran's gastrointestinal disorders started in 1976 after Bilroth II surgery, presumably due to excess alcohol intake, which may have caused peptic ulcer disease vs. toxic injury to the gastric mucosa, and the Veteran subsequently suffered from multiple gastric abnormalities. Also, there is potential aggravation relationship between excessive alcohol intake and GI conditions because in the May 2016 medical opinion, the VA examiner stated that alcohol in high concentrations damages the gastric mucosal barrier to hydrogen ions and is associated with acute gastric mucosal lesions characterized by mucosal hemorrhages, and alcohol also stimulates acid secretion. The examiner also stated that contents of alcoholic beverages other than alcohol are also strong stimulants of acid secretion. As far relationship of medications used to control the service-connected disabilities and aggravation of GI conditions is concerned, in the August 2021 opinion, the examiner did not address this. However, the examiner included the information from the May 2016 medical opinion, in which the examiner stated that there can be other causes of current stomach problems post Bilroth II, such as NSAID or chronic opioid use. Hence, the Board finds that there is potential relationship between the medications and the Veteran's current GI conditions. (Continued on the next page) The Board could remand the matter again for addendum medical opinion, but a request for another opinion could be construed as obtaining additional evidence for the sole purpose of denying the claim, which is impermissible. See 38 C.F.R. § 3.304(c) ("The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination"). Consequently, upon review of the record and based on the above analysis, the Board finds the evidence is in favor or at least be in equipoise as to whether the Veteran's current GI conditions are proximately due to the 1976 gastric surgery resulting from alcohol abuse as self-medication to control the symptoms of the service-connected PTSD; or otherwise, were aggravated by the alcohol abuse and/or medication used to control the Veteran's service-connected disabilities. Accordingly, after resolving all doubt in favor of the Veteran, entitlement to service connection for a GI condition is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Tariq, Nadeem, 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.