Citation Nr: 21028927 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 17-25 800 DATE: May 12, 2021 ORDER Entitlement to service connection for cirrhosis of the liver is granted. FINDING OF FACT Resolving reasonable doubt in favor of the Veteran, his cirrhosis of the liver is proximately due to his service-connected posttraumatic stress disorder (PTSD). CONCLUSION OF LAW The criteria for entitlement to service connection for cirrhosis of the liver have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1976 to July 1979 and from January 1982 and January 1986, with additional service in the National Guard and Reserves. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge; a transcript of the hearing has been associated with the record. The Board notes that additional pertinent evidence was associated with the claims file since the April 2017 statement of the case. However, as the Board is granting the claim on appeal, the Veteran is not prejudiced by proceeding without AOJ consideration. Entitlement to service connection for cirrhosis of the liver The Veteran contends that his cirrhosis of the liver was caused by heavy drinking as a result of his service-connected posttraumatic stress disorder (PTSD). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Generally, to establish service connection, there must be competent, credible evidence of 1) a current disability, 2) in-service incurrence or aggravation of an injury or disease, and 3) a nexus, or link, between the current disability and the in-service disease or injury. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Additionally, and relevant in this case, service connection may also be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Also, an increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. See 38 C.F.R. § 3.310 (b); Libertine v. Brown, 9 Vet. App. 521 (1996); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) competent evidence establishing that the service-connected disability caused or aggravated the nonservice-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995). 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. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In April 2016, the Veteran was afforded a VA examination and was diagnosed with cirrhosis of the liver. Accordingly, the first element of secondary service connection is met. Furthermore, service connection is in effect, as relevant for the claim on appeal, for PTSD. As such, the second element of secondary service connection is also met. As noted above, in April 2016, the Veteran was afforded a VA examination. The Veteran reported that he did a lot of heavy drinking while in the military and that his heavy drinking was related to his PTSD. The Veteran also reported that he stopped drinking about ten years prior and has a family history of liver disease. The VA examiner found that the Veteran's cirrhosis of the liver is less likely than not proximately due to or the result of the Veteran's service-connected PTSD as the Veteran has nonalcoholic fatty liver disease (NAFLD) that is more likely than not related to his obesity, diabetes mellitus type II, dyslipidemia, and hypertension. The examiner explained that patients with NAFLD (particularly those with nonalcoholic steatohepatitis (NASH)), often have one or more components of the metabolic syndrome (obesity, systemic hypertension, dyslipidemia, and insulin resistance or overt diabetes). Additionally, the VA examiner noted that NAFLD refers to the presence of hepatic steatosis when no other causes for secondary hepatic fat accumulation (i.e., heavy alcohol consumption) are present and may progress to cirrhosis. Nevertheless, in November 2016, the Veteran submitted a nexus opinion from his VA treating physician, Dr. C.C., who noted that the Veteran is seen for Decompensated Cirrhosis with complications of Hepatic Encephalopathy. The VA physician noted the Veteran's military experience, to include reports from the Veteran that he began drinking alcohol heavily in 1990 for over 10 years, and that he is being seen by the Behavioral Medicine services for treatment of his service-connected PTSD. While the VA physician noted that the Veteran also has nonalcoholic-steatohepatitis (NASH), which can also contribute to cirrhosis, it is her belief that the Veteran's current condition of cirrhosis of the liver is more likely than not related to the Veteran's PTSD events that occurred during the Veteran's military service. After review of the Veteran's VA treatment records, to specifically include those from November 2014 when the Veteran was first diagnosed with cirrhosis of the liver, it is noted that the etiology of the Veteran's cirrhosis is unclear. Furthermore, throughout the course of treatment for the Veteran's cirrhosis, he has been noted to have NAHLD cirrhosis, NASH and alcoholic liver cirrhosis. See VA treatment records. Therefore, following a review of the record, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran's cirrhosis of the liver is proximately due to his service-connected PTSD. The Board finds the lay statements made by the Veteran regarding the onset of his PTSD symptoms, to include heavy drinking, during active duty and following service to be credible. Additionally, as there are conflicting medical opinions, the evidence is at least in equipoise on the nexus element. When comparing the probative value of these opinions, neither of them is especially conclusive either way. It is clear that both of medical examiners carefully reviewed the record and provided an opinion based on their understanding of the medical science at issue in the context of this Veteran's case. While the April 2016 VA examiner's rationale focused on medical risk factors that can contribute to cirrhosis of the liver and that are present with the Veteran, the November 2016 VA physician's opinion relied more on firsthand knowledge of the Veteran's condition, and the Board also notes that she is documented throughout the Veteran's VA treatment records as treating the Veteran for his liver condition. Accordingly, affording the Veteran the benefit of the doubt, the Board finds that the evidence is at least in equipoise as to whether the Veteran's cirrhosis of the liver is proximately due to or the result of the Veteran's service-connected PTSD. Consequently, service connection is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. B. Smith, 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.