Citation Nr: 21029090 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 15-05 242 DATE: May 12, 2021 ORDER Entitlement to service connection for a gastrointestinal disorder other than gastroesophageal reflux disease (GERD) (previously characterized as stomach trouble (spasm and deformity of the duodenal bulb)) is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran has a current gastrointestinal disorder other than GERD (i.e., peptic ulcer, ileus, gallbladder disorder status post cholecystectomy, and diverticulosis) that began during active service, is related to an in-service injury or disease, or is secondary to a service-connected disability. CONCLUSION OF LAW The criteria for service connection for a gastrointestinal disorder other than GERD 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 honorable active military service from November 1970 to September 1972. The Veteran reportedly died in September 2018 during the pendency of this appeal. The appellant is the Veteran's surviving spouse and has been substituted as the claimant in this appeal pursuant to 38 U.S.C. § 5121A; 38 C.F.R. § 3.1010. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a Department of Veterans Affairs (VA) Regional Office (RO)'s October 2013 decision. In August 2018, the Board remanded the issue on appeal for additional development. The Board finds that substantial compliance with the prior remand has been accomplished. Substantial compliance with a remand order, not strict compliance, is required. See Donnellan v. Shinseki, 24 Vet. App. 167, 176 (2010); Dyment v. West, 13 Vet. App. 141, 147 (1999). Therefore, the Board may proceed forward with adjudicating the Veteran's claim without prejudice to him. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Board further notes that, in August 2018, it also remanded the matters of entitlement to VA non-service-connected disability pension benefits prior to December 23, 2015. The processing of that issue on remand remains in progress at the RO and has not yet been recertified to the Board for further appellate review as of this time. Therefore, that issue will be the subject of a separate future Board decision. Entitlement to service connection for a gastrointestinal disorder other than GERD (previously characterized as stomach trouble (spasm and deformity of the duodenal bulb)) The Veteran (and now the appellant) contends that he had the onset of stomach trouble (spasms and deformity of duodenal bulb) while in Germany during active military service. See January 2014 VA Form 21-4138. 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 question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the evidence shows the Veteran has been treated since his active service for the following gastrointestinal disorders peptic ulcer, ileus, gallbladder disease status post cholecystectomy, and diverticulosis; and evidence shows that the Veteran was treated once in-service in March 1971 for complaints of stomach and/or abdominal pain that was treated with Maalox, the preponderance of the evidence weighs against finding that the Veteran has any gastrointestinal disability that began during service or is otherwise related to an in-service injury, event, or disease. The Board remarks that the Veteran had also claimed service connection for gastroesophageal reflux disease (GERD). However, that condition is not being considered at this time as that issue was dismissed as withdrawn in the Board's August 2018 decision. The Veteran's service treatment records do not show that he was diagnosed with any chronic gastrointestinal disorder during his active military service. Rather, post-service treatment records show the Veteran was not diagnosed with a peptic ulcer until June 1975, diverticulosis until September 2009 and ileus and gallbladder disease until December 2012, years after his separation from service. While the Veteran is competent to report having experienced symptoms he relates to "stomach trouble," neither he nor the appellant are competent to provide a diagnosis in this case or determine that these symptoms were manifestations of any of his diagnosed gastrointestinal conditions as the issue is medically complex, requiring expert medical knowledge, knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Further, in February 2020, a VA clinician opined that the Veteran's peptic ulcer, gallbladder disease, ileus and diverticulosis were not at least as likely as not related to an in-service injury, event, or disease, including the in-service treatment in March 1971. Regarding the claimed condition of peptic ulcer, the examiner stated that the most common causes of peptic ulcers are infection with the bacterium Helicobacter pylori and long-term use of aspirin and NSAIDS (nonsteroidal anti-inflammatories). Stress and spicy foods do not cause peptic ulcer (Mayo Clinic). The examiner further stated that the Veteran's service treatment records document no history (provided by Veteran) or physical findings on entrance examination, exit examination or treatment notes during military of any diagnosis or symptoms of a peptic ulcer. The examiner acknowledged that the Veteran was seen on one occasion in March 1971 per the service treatment records with complaints of stomach pains and examination showed lower abdominal pain and "soreness." A diagnosis was deferred, and the Veteran was prescribed antacids. No further documentation of any ongoing stomach or gastrointestinal problems found in the service treatment records to establish any chronic gastrointestinal complaints and/or symptoms. Based on the evidence, therefore, the examiner found that the March 1971 episode was a one-time self-limiting issue. Rather, the Veteran was diagnosed approximately two years after leaving service with gastrointestinal upset, which led to a diagnosis of peptic ulcer. Per his medical records, this was treated over a four-year period and resolved with treatment with H2 blockers per gastrointestinal series in September 1978 that reported an essentially normal examination. Medical records and upper gastrointestinal findings from 1979 to 2018 contain no reports of any further peptic ulcer complaints or issues. The examiner concluded that a thorough review of Veteran's medical evidence and peer reviewed medical evidence does NOT establish a nexus between the Veteran's military service, or any symptoms therein, to peptic ulcers. As to the diagnosis of ileus, the VA clinician stated that the Veteran was noted in December 2012 radiology findings of the abdomen to have a moderate gastric ileus secondary to mild constipation. Citing to the Mayo Clinic and WebMD, the examiner explained that an ileus is a temporary and often painful lack of movement in the bowel. Per the medical records reviewed, this was a one-time acute, non-recurring condition that resolved with treatment. Therefore, the clinician concluded that a thorough review of Veteran's medical evidence and peer reviewed medical evidence does not establish a nexus between the Veteran's military service, and any symptoms therein, and the diagnosed ileus in 2012, which was 40 years post military. As for gallbladder disease status post cholecystectomy, the examiner noted that this was diagnosed in 2012, 40 years after the Veteran left service, and resulted in surgical intervention (i.e., "cholecystectomy"), which resolved the gallbladder disorder. The clinician remarked that gallstones are hardened deposits of digestive fluid that can form in the gallbladder. Risk factors for gallbladder disease are being overweight and eating a high cholesterol diet, which the Veteran met as his body mass index (BMI) was 31 and he was diagnosed with hyperlipidemia. Therefore, the clinician concluded that a thorough review of Veteran's medical evidence and peer reviewed medical evidence does not establish a nexus between the Veteran's military service, and any symptoms therein, and the diagnosed gallbladder disease in 2012, which was 40 years post military. Finally, the VA clinician addressed the Veteran's diagnosed diverticulosis. The clinician noted that the Veteran was diagnosed with diverticulosis on radiology findings from CT scan and colonoscopy in 2009 and 2010. He remarked that diverticulosis is a condition in which small, bulging pouches develop in the digestive tract, and is common in people over age of 40 (noting the Veteran was 59 to 60 at the time of his diagnosis). Usually no symptoms occur unless the diverticula become inflamed or infected. Treatment consists of diet modifications including dietary fiber. A low fiber diet leads to constipation, which increases pressure within the digestive tract with straining during bowel movements. The combination of pressure and straining over many years likely leads to diverticulosis (Mayo Clinic). Therefore, the clinician concluded that a thorough review of medical evidence and peer reviewed medical evidence does not establish a nexus between the Veteran's service, and symptoms therein, and the diverticulosis diagnosed in 2009 (37 years post military). The VA clinician's opinions are probative as they are based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Neither the Veteran nor the appellant have submitted any medical opinions contrary to the opinions submitted by the VA clinician other than their own statements of opinion as to the etiology of the Veteran's current gastrointestinal disorders. The Board acknowledges the Veteran and appellant's belief that the stomach symptoms noted in service was the onset of his post-service gastrointestinal disorders, including a peptic ulcer, ileus, gallbladder disease and diverticulosis. However, in this case, they are not competent to provide a nexus opinion regarding this issue as it is medically complex and requires knowledge of medicine including the interaction between multiple organs in the body, pathology, and the interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran and the appellant in this case because the record does not show that they have the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the medical opinions provided by the VA clinician in February 2020. The Board further notes that the Veteran's and appellant's reports of in-service and post-service treatment do not agree with the facts as shown in the contemporaneous medical records. They report that the Veteran's symptoms started while he was in Germany during service. However, the March 1971 treatment in service was two months prior to the Veteran being sent to Germany. His service treatment records thereafter are silent for any stomach or lower abdominal complaints and nothing was noted on his April 1972 separation examination. Furthermore, the earliest evidence of treatment for stomach complaints after service in not until August 1974, almost two years after his discharge from active duty, which is not consistent with the Veteran's report that he immediately went for treatment at the VA after his discharge from service in September 1972. Given these inconsistencies, the Board finds the lay statements lack credibility in this regard and the contemporaneous evidence is more probative as to the events that occurred. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); see also Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996), superseded in irrelevant part by statute, VCAA, Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000). It is also possible the Veteran's recollections may simply be mistaken due to the fallibility of human memory for events that occurred decades ago. This is consistent with the law's view of memory in general. See generally, Seng v. Holder, 584 F.3d 13, 19 (1st Cir. 2009) (notwithstanding the declarant's intent to speak the truth, statement may lack credibility because of faulty memory). Hence the Board finds that the inconsistencies in the evidence diminish the Veteran's credibility such that it reduces the probative value of his assertions. The Board also acknowledges the assertions that the Veteran's gallbladder disease, ileus and diverticulosis are secondary to his long-standing stomach troubles. However, the Veteran was not service-connected for any "stomach troubles." Although he had a claim for service connection for GERD, he withdrew the appeal of that claim and it was dismissed in the August 2018 Board decision. Consequently, there is no basis for consideration of secondary service connection for these conditions. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S.M. Kreitlow 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.