Citation Nr: 21070471 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 16-17 240 DATE: November 24, 2021 REMANDED Entitlement to service connection for a gastrointestinal disability, to include chronic gastritis and gastroesophageal reflux disease (GERD), is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1974 to November 1974. This matter is before the Board of Veterans' Appeals (Board) on appeal from a December 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned at a hearing in July 2019. A transcript is of record. The Board remanded this matter in October 2019, November 2020, and June 2021 for additional development. The matter is now returned to the Board for further appellate review. The Veteran contends his current gastrointestinal disability began while on active duty and has continued since. The Veteran has advanced multiple theories and provided medical literature to support his position, which have not been addressed by a medical professional. The Board regrets further delay; however, a remand is necessary to adequately address the Veteran's contentions and clarify his current gastrointestinal disabilities. First, the Veteran contends his current gastritis, attributed, in part, to April 2013 and April 2014 helicobacter pylori (H. pylori) diagnoses, is a continuation of an undiagnosed H. pylori infection that was present while he was on active duty. Specifically, the Veteran contends his in-service complaints of gastrointestinal pain were actually caused by H. pylori and were not somatic manifestations of a mental health condition; however, because the medical understanding of the relationship between H. pylori and gastritis and peptic ulcer disease was unknown to the medical community until approximately 1982, medical providers diagnosed him with a somatic gastrointestinal condition due to the stress of basic training and separation from his family. In other words, the Veteran contends the in-service diagnosis of a somatic gastrointestinal condition was made in error and his H. pylori infection went undiagnosed while on active duty and caused his current gastritis. The Veteran submitted a positive nexus opinion from Dr. J.W.W. Dr. J.W.W. provided a positive nexus opinion between the Veteran's current gastritis and his somatic gastrointestinal pain, in part, because peptic ulcer disease can be chronic or recurrent and is most often related to an H. pylori infection, which the Veteran may have had (undiagnosed) during active duty. Dr. J.W.W. also indicated he did not believe a test for H. pylori was available in 1974. In conjunction with the private medical nexus opinion, the Veteran submitted the above referenced medical literature discussing a positive relationship between H. pylori and gastritis and peptic ulcer disease. The article indicates the relationship between H. pylori and gastritis and peptic ulcer disease was not fully known until approximately 1982. Moreover, the article indicates the belief that stress and lifestyle, which were previously considered the major causes of peptic ulcer disease, was incorrect and that H. pylori causes more than 90 percent of duodenal ulcers and up to 80 percent of gastric ulcers. The Veteran testified at the July 2019 hearing he was hospitalized in 1974/1975 for a bleeding ulcer and attempted to obtain the medical records showing his hospitalization; however, he was unable to obtain records prior to 1980. He did submit records from the same hospital showing multiple gastritis complaints and treatments from 1980 onward. The Veteran is competent and credible to discuss being hospitalized and the associated diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Whether the Veteran's in-service diagnosis of a somatic gastrointestinal condition was made in error because the medical understanding of the relationship between H. pylori and gastritis and peptic ulcer disease was unknown to the medical community at the time and he actually had an undiagnosed H. pylori infection, which may, in part, have caused his current gastritis, is a medical determination to be made by a medical professional. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA is not permitted to base decisions on its own unsubstantiated medical conclusions). The second contention is the Veteran's service treatment records (STRs) contain an inconsistency that resulted in a somatic gastrointestinal diagnosis as opposed to a physical disorder. Specifically, Dr. J.W.W. reported the November 1974 EGD with biopsy contained a notation of "friable mucosa"; the EGD biopsy pathology report was abnormal and consistent with chronic gastritis; and the "...biopsy was (erroneously) said to have been 'normal' in a later narrative hospital note." Dr. J.W.W. reported that if this erroneous note was relied on at the time of the Veteran's discharge from active duty, it may have contributed to a mistaken impression that his stomach problem was "psychological" or not a "physical disorder." See April 2014 Dr. J.W.W. Letter. Again, whether the Veteran's biopsy was erroneously reported as normal and attending physicians relied on this error when rendering the somatic gastrointestinal condition diagnosis is a medical determination to be made by a medical professional. Colvin, 1 Vet. App. at 175. Further, in the June 2021 remand the Board requested the April 2021 examiner provide an addendum opinion addressing whether it is at least as likely as not that the Veteran had irritable bowel syndrome (IBS) at any point during the appeal period, which started in approximately July 2014. In a July 2021 Disability Benefits Questionnaire (DBQ), the April 2021 examiner reported the Veteran has not had IBS at any point during the appeal period, which the Veteran confirmed in the September 2021 Informal Hearing Presentation (IHP). The April 2021 examiner; however, also reported there is no pathology to render a gastroesophageal reflux disease (GERD) diagnosis "...at this time." See July 2021 DBQ. In the April 2021 medical nexus opinion, the April 2021 examiner previously indicated the Veteran does have GERD. The Board is unclear whether the Veteran did not meet the criteria for a GERD diagnosis at the time the examiner provided the July 2021 DBQ or whether the Veteran has never met the diagnostic criteria for GERD throughout the entire appeal period. See Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (Board must obtain an opinion addressing whether diagnoses in the record were made in error where a VA examiner finds that there is no current diagnosis). Lastly, in the September 2021 IHP, the Veteran's representative noted there are additional inconsistencies between the April 2021 medical nexus opinion and the July 2021 addendum medical nexus opinion. In the April 2021 negative nexus opinion, the April 2021 examiner reported the Veteran has a history of gastritis, GERD, and treatment for H. Pylori since leaving active duty but notes the Veteran's private physician reported the Veteran has not had a peptic ulcer at any point. The April 2021 examiner relied, in part, on the absence of a documented peptic ulcer to support a negative nexus opinion for chronic gastritis and GERD. In the July 2021 addendum opinion; however, the April 2021 examiner relied on the Veteran's report of having an ulcer to support the conclusion that the Veteran does not have IBS. The Board cannot reconcile the differences between the April 2021 nexus opinion and the July 2021 addendum opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide an examination, it must provide an adequate one). The matter is REMANDED for the following action: Obtain a medical opinion, preferably from a clinician that has not previously examined the Veteran or provided a nexus opinion, regarding the nature and etiology of any current gastrointestinal disability, to include chronic gastritis and GERD. The entire claims file must be made available to and be reviewed by the selected clinician. The Veteran should only be scheduled for a new examination if deemed necessary by the selected clinician. Following review of the claims file and, if indicated, examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that any gastrointestinal disability, including chronic gastritis and GERD, began in or is otherwise caused by the Veteran's active service. If the clinician determines that the Veteran has not had a gastrointestinal disability, including chronic gastritis or GERD, at any point during the appeal period, the examiner must explain why he or she concluded that the diagnoses of chronic gastritis or GERD reflected in the record was made in error. The examiner should address all relevant medical evidence of record. In providing the requested opinions, the examiner should specifically address the following evidence regarding ongoing gastrointestinal complaints: (a) the Veteran's testimony at the July 2019 hearing that he was hospitalized in 1974/1975 for a bleeding ulcer; (b) the medical records from Lyndon B. Johnson Medical Center in American Samoa from 1980 to 1991 documenting complaints and treatments for a gastrointestinal condition; and (c) the April 2014 and April 2016 letters provided by the Veteran's private physician, J.W.W., MD. The examiner is also asked to address the Veteran's specific contentions, including: (a) The first contention is that the Veteran's current gastritis, attributed, in part, to April 2013 and April 2014 H. pylori diagnoses, is a continuation of an undiagnosed H. pylori infection that was present while the Veteran was on active duty but not recognized or diagnosed because the medical understanding of the relationship between H. pylori and gastritis and peptic ulcer disease was unknown to the medical community at that time and a test for H. pylori did not exist in 1974. When addressing this contention, the selected clinician must address the medical article the Veteran submitted in support of this proposition. (b) The second contention is that the Veteran's service treatment records contain an inconsistency which may have contributed to a mistaken impression that his stomach problem was "psychological" or not a "physical disorder." In this regard, the selected clinician must address the April 2016 letter from Dr. J.W.W. alleging that the November 1974 EGD with biopsy contained a notation of "friable mucosa"; the EGD biopsy pathology report was abnormal and consistent with chronic gastritis; and the "...biopsy was (erroneously) said to have been 'normal' in a later narrative hospital note." The clinician is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the clinician rejects the Veteran's reports, he or she must provide a reason for doing so. The fact that his report of symptoms is not corroborated by contemporaneous medical treatment records is not, by itself, a sufficient reason to reject the Veteran's report of injury and symptoms capable of lay observation. If the examiner finds the Veteran's gastrointestinal disability is due to post-service factors, such as diet, weight, or post-service employment, rather than military service, the examiner must explain why the gastrointestinal disability would be MORE likely due to the post-service factor rather than the Veteran's active-duty service. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Zachery S.C. Luce, 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.