Citation Nr: 21021274 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 16-21 236 DATE: April 12, 2021 ORDER Entitlement to service connection for gastroesophageal reflux disease (GERD), claimed as acid reflux, to include as secondary to service-connected posttraumatic stress disorder (PTSD) or medications taken for service-connected disabilities is denied. FINDING OF FACT The Veteran’s GERD is neither proximately due to nor aggravated beyond its natural progression by his service-connected PTSD or medications taken for service-connected disabilities, and is not otherwise related to an in-service injury, event, or disease. CONCLUSION OF LAW The criteria for service connection for GERD, to include as secondary to service-connected PTSD or medications taken to treat the Veteran’s service-connected disabilities, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.102, 3.303, 3.310 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1966 to January 1969. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a September 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This claim was previously before the Board in September 2018, September 2019, and September 2020 at which times the Board remanded it for additional development. Entitlement to service connection for gastroesophageal reflux disease (GERD), claimed as acid reflux, to include as secondary to service-connected posttraumatic stress disorder (PTSD) or medications taken for service-connected disabilities The Veteran asserts entitlement to service connection for GERD, to include on a secondary basis. Specifically, the Veteran contends that his GERD is secondary to service-connected PTSD. Alternately, the Veteran contends that he has GERD secondary to medications taken for service-connected disabilities. Service connection will be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection requires competent evidence showing, (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Once the evidence has been assembled, it is the Board’s responsibility to evaluate the evidence. 38 U.S.C. § 7104 (a). The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.102, 4.3. Initially, the Board finds that the Veteran has been diagnosed with GERD. See October 2020 VA Examination Report. Next, the Board notes that GERD is not a chronic disability under 38 C.F.R. § 3.309 (a), thus, service connection is not warranted on a presumptive basis or based on continuity of symptomatology. 38 C.F.R. §§ 3.303, 3.307. Concerning direct service connection, for the reasons that will be set forth below, the Board finds that the Veteran’s GERD has not been related to service or to a service-connected disability, to include medications. A review of the Veteran’s service treatment records (STRs) shows a normal abdomen and viscera (including hernia) and no complaints or treatment for any gastrointestinal condition. See April 1966, September 1968, and May 1973 STRs. The Board notes that the Veteran has been service-connected for PTSD since March 2015. See September 2015 Rating Decision. The Veteran also takes medications for his service-connected disabilities, including PTSD and hypertension. See October 2020 VA Examination Report. In accordance with the September 2020 Board remand, a VA addendum medical opinion was obtained in October 2020. The VA examiner opined that the Veteran’s GERD is less likely than not proximately due to or aggravated by the Veteran’s service-connected disabilities, to include medication. The VA examiner stated that, the medical literature supports GERD occurs when acid backs up into the esophagus which can be due to poor esophageal motility, a dysfunctional lower esophageal sphincter, delayed gastric emptying, or a hiatal hernia. The VA examiner noted that the Veteran’s GERD was reported in 1981, prior to his PTSD diagnosis. Therefore, the Veteran’s GERD is not caused by his service-connected PTSD. Regarding aggravation, the VA examiner opined that the Veteran’s GERD is less likely than not aggravated beyond its natural progression by his service-connected PTSD. In support of this opinion, the VA examiner reasoned that the Veteran’s April 1981 upper GI series showed evidence of GERD based on results of hiatal hernia with reflux. While PTSD sufferers with anxiety report worsening of acid reflux symptoms, there is no evidence to suggest that anxiety and stress affect the motility of the esophagus, the pressure of the lower esophageal sphincter, gastric emptying, or lead to a hiatal hernia. The VA examiner also addressed the November 2019 VA examiners statement that there was a reasonable theory that PTSD could cause increased cortisol levels resulting in GERD, as directed in the September 2020 Board remand. The VA examiner stated that the previous VA examiner noted this belief without documentation of medical literature from a reputable source and the statement should be disregarded. The VA examiner reasoned that, while PTSD sufferers with anxiety report a worsening of acid reflux symptoms, there is no evidence to suggest that anxiety and stress affect the motility of the esophagus, the pressure of the lower esophageal sphincter, gastric emptying, or lead to a hiatal hernia. Thus, a nexus is not established secondary to the Veteran’s service-connected PTSD. The VA examiner noted that the Veteran takes Lexapro for PTSD since 2007 and Amlodipine for hypertension since 2004. The VA examiner reasoned, in regards to the Veteran’s medications for his service-connected disabilities, the Veteran’s service-connected musculoskeletal conditions, peripheral nerve condition, and a laceration of the conjunctiva are separate conditions from the GERD diagnosed in 1981, and the medical literature does not support NSAID use as treatment for musculoskeletal conditions as a cause of GERD. Regarding any aggravation due to medication, the VA examiner noted common Lexapro side effects include nausea, diarrhea, abdominal pain, constipation, dry mouth, dyspepsia, flatulence, indigestion, toothache, and committing. Gastrointestinal side effects were noted with the use of Lexapro; however, the evidence did not show it affected the motility of the esophagus, pressure of the lower esophageal sphincter, gastric emptying, or lead to a hiatal hernia. The VA examiner also noted, in accordance with the September 2020 Board remand directives, that while the June 2020 opinion shows calcium channel blockers such as Amlodipine can cause GERD by inducing LES hypotension, the Veteran’s records do not show evidence of Barrett’s esophagitis, esophageal ulcers, or esophageal cancer, which are known complications of GERD and do not support aggravation beyond natural progression of GERD. Thus, a nexus is not established based on medication for service-connected disabilities. The Board finds the October 2020 VA medical opinion to be highly probative as to whether the Veteran’s currently diagnosed GERD is related to service, to his service-connected PTSD, or medications taken for service-connected disabilities. The examiner reviewed and discussed the medical evidence of record and the Veteran’s pertinent history. Further, the medical opinions were supported by well-reasoned rationales, which were consistent with the medical evidence of record. See Prejean, 13 Vet. App. at 448-9; Hernandez-Toyens, 11 Vet. App. at 382. The remaining medical evidence, to include post-service VA and private treatment record, show complaints and treatment for GERD, but does not address whether there is a link between the GERD and service or to a service-connected disability or medications. The Board has also considered the Veteran’s statements regarding his belief that he has GERD that is related to his service-connected PTSD or medications taken for service-connected disabilities. As a lay person; however, the Veteran does not have the requisite medical knowledge, training, or experience to be able to provide a medical opinion between his currently diagnosed GERD and his service-connected PTSD or medications taken for service-connected disabilities. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). Additionally, GERD is a medically complex process because of its multiple possible etiologies, as noted by the October 2020 VA examiner. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The etiology of the Veteran’s GERD is also a complex medical etiological question because it involves internal and unseen system processes unobservable by the Veteran. For these reasons, and based on the evidence of record, the Board finds that the weight of the competent, credible, and probative evidence is against a finding of relationship between the Veteran’s GERD and service, his service-connected PTSD, or medications taken for service-connected disabilities. The Board finds that a preponderance of the evidence is against the claims for service connection for a GERD, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. C. Slaughter, 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.