Citation Nr: 21007223 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 11-28 932 DATE: February 9, 2021 ORDER Service connection for a gastrointestinal disability is denied. FINDING OF FACT The Veteran’s gastroesophageal reflux disease (GERD) and gastritis are not secondary to service-connected posttraumatic stress disorder (PTSD) and are not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for a gastrointestinal disability due to service or a service-connected disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the U.S. Army from March 1964 to March 1966. This matter comes before the Board of Veterans Appeals’ (Board) on appeal from an April 2011 rating decision. It was previously remanded by the Board for additional development in March 2016, May 2017 and April 2019. Service connection for a gastrointestinal disability Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 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). The Board concludes that, while the Veteran has diagnoses of GERD and gastritis, the preponderance of the evidence is against finding that these conditions began during active service, or are otherwise related to an in-service injury, event, or disease. Service treatment records are negative for any complaints, treatment or diagnoses of a gastrointestinal condition. The Veteran’s January 1966 separation examination was normal, and he denied having any relevant symptoms on the accompanying medical history report. In addition, the Veteran had a period of active duty for training from May 27, 1967 to June 10, 1967 and indicated that there had been no changes in his condition during that time. The Veteran was not diagnosed with GERD until 2001, about 34 years after his period of active duty for training. In his May 2010 claim for benefits, he indicated that his stomach condition had its onset in 2005. During a March 2018 VA examination, he reported having acid reflux for many years, but did not assert that it began during service. Based on the above, the overall weight of the evidence is against a finding that a relevant in-service event, injury or disease occurred with respect to a gastrointestinal condition. Alternatively, the Veteran contends that his gastrointestinal disabilities are secondary to his service-connected PTSD, including treatment for PTSD. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The Board concludes that, while the Veteran has current disabilities of GERD and gastritis, the preponderance of the evidence is against finding that they are proximately due, the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). In an October 2018 opinion, a VA examiner stated that the Veteran’s gastrointestinal conditions were less likely than not related to his PTSD. He cited medical literature explaining that psychological factors can play a role in gastrointestinal illness, but only in about 30 percent of individuals with GERD. Moreover, those individuals had general psychological distress rather than specific psychiatric disorders. The examiner concluded that while PTSD may be a contributing factor, it would be speculative to limit the Veteran’s psychological distress to his PTSD. An additional VA opinion was obtained in November 2019. That examiner also stated that the Veteran’s gastrointestinal conditions were less likely than not caused or aggravated by PTSD. He cited to medical literature, which failed to show that GERD or gastritis are caused or aggravated by PTSD or its treatment (including medications used by the Veteran: Sertraline, Mirtazapine, Zolpidem and Vistaril). Notably, at the time of the Veteran’s GERD and gastritis diagnoses, he was not diagnosed with or being treated for PTSD, which strongly suggests that PTSD did not cause GERD or gastritis. Regarding aggravation, the examiner stated that there was no aggravation (i.e., worsening) of the condition beyond its natural progression since the Veteran began treatment for PTSD. A review of the Veteran’s treatment records corroborates this statement. VA records from March 2006 show the Veteran experienced reflux, acidity and gas. Additional records from November 2008 show that his GERD was symptomatic despite treatment with diet and medication. Indeed, in November 2009, after the diagnosis of PTSD, reflux was noted to be “controlled.” In November 2011, VA treatment records show that the Veteran experienced reflux sometimes, and that he was not fully compliant with is medication. Multiple entries document the absence of vomiting or abdominal pain, though acid reflux, gas and abdominal pain were noted in February 2016. In June 2016, it was noted that his reflux remained active despite medication changes. VA will not concede that a nonservice-connected condition was aggravated by a service-connected disability unless the baseline level of severity of the nonservice-connected condition is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected condition. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 CFR Part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). Under 38 C.F.R. § 4.114, Diagnostic Code 7346 for hiatal hernia, a 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is warranted for two or more of the symptoms for the 30 percent evaluation of less severity. Based on the evidence discussed above, the Veteran’s GERD and gastritis resulted in symptoms such as regurgitation and pyrosis, but was not shown to be productive of considerable impairment of health, either before or after the onset of his PTSD and associated treatment. Therefore, because GERD did not increase in severity, aggravation cannot be established. To the extent that the Veteran has asserted that his GERD and gastritis are associated with his PTSD, he has not been shown to have the necessary medical knowledge or training to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of anatomical relationships and the interaction between multiple organ systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Because a competent link between the Veteran’s gastrointestinal disabilities and his service-connected PTSD has not been established, service connection on a secondary basis is not warranted. JOHN Z. JONES Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Shamil Patel, 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.