Citation Nr: 21020703 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 19-34 813 DATE: April 8, 2021 ORDER Service connection is granted for a gastrointestinal disorder, to specifically include hiatal hernia and gastroesophageal reflux disease (GERD). FINDING OF FACT The Veteran’s gastrointestinal disorder, to specifically include hiatal hernia and GERD is related to an in-service injury, event, or disease. CONCLUSION OF LAW The criteria for service connection for a gastrointestinal disorder, to specifically include hiatal hernia and GERD, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1963 to September 1967, to include service in the Republic of Vietnam. On appeal is an August 2018 rating decision issued by a Department of Veteran Affairs (VA) Regional Office (RO) that denied service connection for 20 issues, including hiatal hernia, colon diverticulosis, and hemorrhoids. When the matter was initially before the Board of Veterans’ Appeals (Board) in August 2020, the Board denied service connection for most of the issues on appeal, but remanded two of the claims for additional development: (1) Entitlement to service connection for a gastrointestinal disorder, to include hiatal hernia, colon diverticulosis, hemorrhoids and GERD; and (2) Entitlement to service connection for vitiligo. After the requested development was completed, the RO, in a September 2020 rating decision, granted service connection for vitiligo. The granting of service connection is considered a full grant of the benefit sought on appeal, so the issue of vitiligo is no longer before the Board for adjudication. The Board will now proceed with adjudication of entitlement to service connection for a gastrointestinal disorder, to include hiatal hernia, colon diverticulosis, hemorrhoids, and GERD. Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Entitlement to service connection for a gastrointestinal disorder to include hiatal hernia, colon diverticulosis, hemorrhoids, and GERD. The Veteran contends that he has a gastrointestinal disorder as a result of his active service. Alternative theories of entitlement have been stated in the record, with the Veteran contending his gastrointestinal disorder is due to his exposure to Agent Orange in Vietnam; his diagnosis of hepatitis during service; and/or his diagnosed skin disease vitiligo, which is now service-connected. As noted above, when the issue was previously before the Board in August 2020, the Board re-characterized the issue as one for service connection of a gastrointestinal disorder to include hiatal hernia, colon diverticulosis, hemorrhoids, and GERD. The question for the Board is whether the Veteran’s current diagnosis of a gastrointestinal disorder began during active service or is etiologically related to an in-service disease or injury. The Board finds that competent, credible, and probative evidence establishes that the Veteran’s gastrointestinal disorder, to specifically include only hiatal hernia and GERD, is etiologically related to his active service. Service treatment records are associated with the Veteran’s claims file. A December 1966 record specifically notes the Veteran was diagnosed with hepatitis in service. The Veteran’s post service VA treatment records from the San Juan VAMC are associated with the file. In summary, these records reflect the Veteran has been treated for complaints of different gastrointestinal disorders over the years. A June 2015 Active Problem List includes diverticulosis. A June 2017 colonoscopy showed diverticulosis and internal hemorrhoid. A June 2018 record reflects a diagnosis of GERD. In December 1967, the Veteran underwent a general VA examination. It was noted the Veteran had a past history of hepatitis while stationed in Vietnam in December 1966 for which he was hospitalized for 6 weeks. Upon examination, he was asymptomatic, and all reviewed systems were noted to be normal. The examiner noted the Veteran reported he eats a regular diet and he does not complain of any abdominal pain, discomfort, vomiting, nausea, or diarrhea. There had been a mild weight loss since discharged from the Army. The examiner diagnosed the Veteran with hepatitis, history of, with no residuals. In January 2018, the Veteran underwent a private examination. The examiner noted the Veteran present with nausea, vomiting, flatulence, fatty food intolerance, and epigastric burning type pain. The examiner stated gastroenterologist work up is compatible with gastritis, hiatal hernia, and colon diverticulosis. The Veteran has been in medical treatment and irritants free/high fiber diet with poor control of symptoms. The examiner noted the Veteran has 23 diagnosed conditions, to include chronic gastritis, hiatal hernia, colon diverticulosis, hemorrhoids, and vitiligo. The examiner opined that the Veteran’s sensorial, cardiovascular, metabolic, and musculoskeletal diseases with psychiatric disorders are more probable than not secondary to his military service performance. No rationale was given for this opinion. In August 2020, the Veteran underwent a VA examination for esophageal conditions. The examiner noted a diagnosis of GERD with symptoms that include reflux and regurgitation. The examiner opined that the Veteran’s gastroesophageal reflux disease is less likely as not caused by or result of active military service. As rationale, the examiner stated, “there is no evidence on service treatment record.” In August 2020, the Veteran underwent a separate VA examination for intestinal conditions. The examiner noted a 2007 diagnosis of diverticulosis and a 2012 diagnosis of internal hemorrhoids. The examiner opined that the condition claimed (diverticulosis) was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event, or illness. As rationale, the examiner stated this is a case of a 76 year old male Veteran who entered active service in September 1963 and was released in September 1967. Colon diverticulosis was diagnosed in January 2007, a date which is 40 years after separation from active service period. The service treatment records are silent regarding any diagnosis or symptoms of colon diverticulosis during active service. There is no evidence of any manifestation or diagnosis of colon diverticulosis within a year after separation from active service. As for hemorrhoids, the examiner opined that the condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event, or illness. As rationale, the examiner stated this is a case of a 76 year old male Veteran who entered active service in September 1963 and was released in September 1967. Hemorrhoids was diagnosed in April 2012, a date which is 53 years after separation from active service period. The service treatment records are silent regarding any diagnosis or symptoms of hemorrhoids during active service. There is no evidence of any manifestation or diagnosis of hemorrhoids within a year after separation from active service. Because the medical opinions noted above did not address skin conditions and hepatitis, as instructed in the August 2020 Board Remand, the RO sought addendum opinions. In October 2020, addendum opinions were obtained from the VA examiners. As it pertains to GERD, the examiner opined that the condition claimed is less likely than not proximately due to, or the result of, the Veteran’s service-connected condition. As rationale, the examiner stated there is no pathophysiology between GERD and vitiligo on medical literature. There is no evidence of GERD on service treatment record as a result of treatment for hepatitis. As it pertains to diverticulosis, the examiner opined that the condition claimed was less likely than not incurred in or caused by skin issues, to include the now service-connected vitiligo, and also the treatment for hepatitis received on active duty. As rationale, the examiner stated medical literature does not support that a skin issue, to include Vitiligo, would be a cause for diverticulosis. Diverticula usually develop when naturally weak places in the colon give way under pressure. This causes marble-sized pouches to protrude through the colon wall. (Hepatitis was not addressed.) In December 2020, a more detailed Addendum medical opinion was obtained. This examiner stated that based on record review, the Veteran uses antivirals for the treatment of hepatitis. Per literature, this produces adverse side effects that explains the symptoms and the diagnosis of Hiatal Hernia and GERD. Thus, it is at least as likely as not that the Veteran’s currently diagnosed Hiatal Hernia and GERD are proximately due to or the result of Veteran’s treatment for hepatitis. The examiner went on to state that on the other hand, the medical literature does not support an etiological link between the currently diagnosed Colon Diverticulosis, Asymptomatic, and Internal Hemorrhoids to the antivirals used for treatment of hepatitis. Thus, it is less likely than not that Veteran’s currently diagnosed Colon Diverticulosis, Asymptomatic, and Internal Hemorrhoids are proximately due to or the result of Veteran’s treatment for hepatitis. In light of the above, while the evidence is not unequivocal, it has nonetheless placed the record in relative equipoise. The Veteran has consistently and credibly reported that he believes his gastrointestinal disorder may be due to his diagnosis of hepatitis in service, and his contentions are supported by the medical evidence of record. Service treatment records document a December 1966 in-service diagnosis of hepatitis; a private January 2018 examiner provided a positive opinion (albeit with no rationale); and, the most recent December 2020 medical opinion provides a positive nexus opinion, noting the medical literature shows treatment of hepatitis produces adverse side effects that explains the symptoms and the diagnosis of hiatal hernia and GERD. (Continued on the next page)   Although the August 2020 VA examiners and October 2020 Addendum reports provided negative opinions, the Board finds these opinions to be inadequate as these opinions did not address hepatitis as instructed in the August 2020 Board Decision and Remand or provided an inadequate one-sentence rationale. As these VA opinions are not adequate, they cannot serve as the basis of a denial of entitlement to service connection. The Board also notes that to the contrary, as noted above, the December 2020 VA examiner who provided an Addendum opinion found the Veteran’s gastrointestinal disorder, to specifically include hiatal hernia and GERD, to be due to the Veteran’s treatment of an in-service disease - hepatitis. Accordingly, the Board finds that the evidence for and against the claim of entitlement to service connection for a gastrointestinal disorder, to specifically include hiatal hernia and GERD, to be at least in equipoise. Therefore, reasonable doubt must be resolved in favor of the Veteran, and entitlement to service connection for a gastrointestinal disorder, to specifically include hiatal hernia and GERD is warranted. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). M. Mills Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Jiggetts 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.