Citation Nr: 21029237 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 14-15 137 DATE: May 13, 2021 ORDER Service connection for anal bleeding is denied. Service connection for an esophageal condition is denied. FINDINGS OF FACT 1. The Veteran's anal bleeding is not related to service, to include exposure to contaminated water at Camp Lejeune, and did not have its onset during service. 2. The Veteran's esophageal condition is not related to service, to include exposure to contaminated water at Camp Lejeune, and did not have its onset during service. CONCLUSIONS OF LAW 1. The criteria for service connection for anal bleeding have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. 1. The criteria for service connection for an esophageal condition have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1953 to August 1956. The case is on appeal from an October 2013 rating decision. In May 2016, the Veteran testified at a Board hearing. Most recently, in September 2020, the Board denied a claim of service connection for a kidney condition, and remanded claims of service connection for anal bleeding and an esophageal condition for additional development. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(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." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). For veterans who are presumed to have been exposed to contaminants in the water supply while serving at Camp Lejeune for no less than 30 days from August 1, 1953, to December 31, 1987, VA has established a presumption of service connection for certain diseases. 38 C.F.R. § 3.307 (a)(7), 3.309(f). Where a presumption does not exist, VA is to consider whether service connection is warranted on a non-presumptive basis. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed.Cir.1994). In addition, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Service connection for anal bleeding. The Veteran is seeking service connection for anal bleeding. He asserts that this condition is related to exposure to contaminated water during his service at Camp Lejeune. Initially, the current disability requirement is established for the anal bleeding claim. A December 2020 VA examination reflects a diagnosis of diverticulosis and internal hemorrhoids. In addition, the evidence of record reflects that the Veteran was noted to have rectal bleeding associated radiation-induced proctitis related to treatment for prostate cancer. Presumptive Service Connection The Board will first address whether presumptive service connection is warranted for anal bleeding as related to exposure to contaminated water at Camp Lejeune. The Veteran's service personnel records (SPRs) confirm he was stationed at Camp Lejeune from December 1953 to July 1954 and from January 1955 to August 1956. Thus, the Veteran served on active duty during the periods known to be associated with presumed exposure to contaminated water. As a result, exposure to contaminants at Camp Lejeune is presumed. However, anal bleeding or any of the diagnosed conditions noted above associated with anal bleeding are not included as diseases associated with such exposure under 38 C.F.R. § 3.309(f) for the purposes of presumptive service connection. As such, service connection cannot be established on a presumptive basis for the claim of service connection for anal bleeding based on exposure to contaminated water at Camp Lejeune. Direct Service Connection Having established presumptive service connection is not warranted, the Board's analysis will now address "direct" service connection. That is, whether the Veteran's conditions characterized by anal bleeding is nevertheless related to service, specifically presumed exposure to contaminated water at Camp Lejeune. The Board finds the evidence of record establishes the occurrence of an in-service injury or event as it concerns the Veteran's exposure to contaminated water at Camp Lejeune. As noted above, the Veteran's service personnel records (SPRs) reflect that the Veteran was stationed at Camp Lejeune during the applicable period; thus, exposure to contaminants has been presumed. Thus, the determinative issue for the Board is whether a nexus, or causal link, exists between the Veteran's active military service and his conditions characterized by anal bleeding. Concerning the question of whether there is a causal link between the Veteran's conditions characterized by anal bleeding and his exposure to contaminated water at Camp Lejeune, the evidence of record includes a December 2020 opinion and an opinion from an examiner who provided an examination in March 2021. The examiner who provided the December 2020 opinion determined that it is less likely than not that the Veteran's anal bleeding was caused by his exposure to contaminated water at Camp Lejeune. He explained that according to the "ATSDR Assessment of the Evidence for the Drinking Water Contaminants at Camp Lejeune and Specific Cancers and Other Diseases" published in 2017 and the general medical literature, there are no known studies cited that document gastrointestinal bleeding (including rectal bleeding) as a sequelae of exposure to Camp Lejeune contaminated water. Instead, the examiner attributed the Veteran's rectal bleeding to hemorrhoids that were documented in a recent colonoscopy. He also noted that that the Veteran radiation proctitis further complicated his rectal bleeding etiology. The examiner who provided an examination in March 2021 concluded that it was less likely than not that the Veteran's anal bleeding was incurred in or caused by the claimed in-service event. The examiner explained that any mention of anal bleeding is absent from the Veteran's STRs. She also noted that on the day of the examination, the Veteran was unable to provide any details regarding it onset. The examiner stated the Veteran reported that his anal bleeding subsided when he began taking medication for his esophageal conditions but continued to experience intermittent episodes of rectal bleeding secondary to his treatment for prostate cancer. The Board acknowledges the Veteran's contentions that his anal bleeding and esophageal conditions are related to exposure to contaminated water at Camp Lejeune. However, the Veteran's statements may not be used to establish a nexus opinion regarding this issue. The issues are medically complex, as they require knowledge of the interaction between multiple organ systems in the body. Therefore, it is outside the competence of the Veteran in this case. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). As such, the Veteran's opinion lacks probative value, and an opinion by a qualified medical expert is required to decide the claims. Consequently, the Board gives more probative weight to the VA opinions described above. The Board finds the opinions, cumulatively, to be persuasive, as they rely on expert knowledge and the Veteran's medical history. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The opinions support that the Veteran's anal bleeding is unrelated to his exposure to contaminated water at Camp Lejeune. In this regard, both opinions are consistent with one another in that they explain that the more likely etiology for the Veteran's anal bleeding is his radiation induced proctitis secondary to his treatment for prostate cancer, with the December 2020 opinion also noting that the Veteran's rectal bleeding was due hemorrhoids that were documented in a recent colonoscopy. In addition, the opinions support that his anal bleeding did not have its onset during service, as it is associated condition his prostate cancer which was diagnosed many years after service, and the Veteran was unable to provide details regarding its onset. Moreover, there is no similar medical opinion of record weighing in favor of service connection. In reaching the conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, under the presumptive and direct theories of service connection, that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection is not warranted for anal bleeding. 2. Service connection for an esophageal condition. The Veteran is also seeking service connection for esophageal condition. He asserts that these conditions are related to his exposure to contaminated water during his service at Camp Lejeune. The current disability requirement is established for the claim of service connection for an esophageal condition. A March 2021 VA examination reflects diagnoses including gastroesophageal reflux disease (GERD) and Barrett's esophagus. Presumptive Service Connection The Board will address whether presumptive service connection is warranted for an esophageal condition as related to exposure to contaminated water at Camp Lejeune. As noted above, the Veteran's exposure to contaminants at Camp Lejeune is presumed. However, GERD and Barrett's esophagus are not included as diseases associated with such exposure under 38 C.F.R. § 3.309(f) for the purposes of presumptive service connection. As such, service connection cannot be established on a presumptive basis for the claim of service connection for an esophageal condition based on exposure to contaminated water at Camp Lejeune. Direct Service Connection Having established presumptive service connection is not warranted, the Board's analysis will now address "direct" service connection. That is, whether the Veteran's conditions characterized esophageal condition are nevertheless related to service, specifically presumed exposure to contaminated water at Camp Lejeune. As previously noted, the Board finds the evidence of record establishes the occurrence of an in-service injury or event as it concerns the Veteran's exposure to contaminated water at Camp Lejeune. The Veteran's SPRs reflect that the Veteran was stationed at Camp Lejeune during the applicable period; thus, exposure to contaminants has been presumed. Thus, the determinative issue for the Board is whether a nexus, or causal link, exists between the Veteran's active military service and his esophageal condition. Concerning this the question of whether there is a causal link between the Veteran's esophageal conditions and his exposure to contaminated water at Camp Lejeune, the evidence of record includes a September 2018 opinion provided by a VA Camp Lejeune contaminated water subject matter expert, a December 2020 opinion, and an opinion provided by an examiner who provided an examination in March 2021. In regard to the September 2018 opinion, the subject matter expert noted a diagnosis of chronic GERD resulting in Barrett's esophagus with a history of esophageal ulcers and hemoptysis that resolved with medication management. He concluded that it is less likely than not that the Veteran's esophageal conditions are due to exposure to contaminated water at Camp Lejeune. The subject matter expert noted that the Veteran was potentially exposed to Camp Lejeune contaminated water for a period of approximately three years and stated that the Veteran was subsequently diagnosed with the claimed condition in 1995, which is approximately 49 years after his service at Camp Lejeune. The subject matter expert noted further that any indication of GERD, pyrosis, or heartburn during service is absent from the Veteran's STRs. The examiner also discussed risk factors for esophageal conditions that apply in the case of the Veteran. In this regard, the examiner stated that the Veteran has a history of GERD, Barrett's disease, obesity, and history of long-term tobacco abuse. He explained further that those who are overweight or obese are more likely to develop esophageal reflux and that smoking is known to worsening reflux. He also noted that chronic reflux is considered the predominant cause of Barrett's metaplasia and may also lead to esophageal ulcers which may bleed with coughing or vomiting. The subject matter expert stated further that there is no medical or scientific correlation between the Veteran's service at Camp Lejeune having resulted in TCE exposure and the subsequent onset of GERD in the 1990s. The subject matter expert stated further that records indicate that the Veteran was a retired metal processor who worked with chemical solvents, and that occupational exposures to solvents are typically of a greater concern than environmental exposures due to increased frequency and concentration. An additional opinion concerning the etiology of the Veteran's esophageal conditions was obtained in December 2020 pursuant to the Board's September 2020 remand to further consider the Veteran's lay statements regarding the onset of his esophageal symptoms. The examiner who provided the December 2020 opinion concluded that it is less likely than not that the Veteran's esophageal conditions were caused by his exposure to contaminated water at Camp Lejeune. The examiner explained that according to the "ATSDR Assessment of the Evidence for the Drinking Water Contaminants at Camp Lejeune and Specific Cancers and Other Diseases" published in 2017 and the general medical literature, there are no studies cited that document GERD, Barrett's esophagitis, or gastrointestinal bleeding as a sequelae of exposure to Camp Lejeune contaminated water. The examiner noted further that the Veteran has known risk factors for Barrett's esophagitis, most notably, long standing GERD, cigarette smoking, and male gender. The examiner cited to numerous articles regarding esophageal conditions. In addition, the Veteran underwent a VA examination in March 2021 pursuant to the Board's September 2020 remand. The examiner concluded that it is less likely than not that the Veteran's esophageal conditions were incurred in or caused by the claimed in-service injury, event, or illness. In this regard, the examiner reported that the Veteran was unable to establish a timeline concerning the onset of hemoptysis. The examiner noted that there were no complaints of heartburn or hemoptysis during service. The examiner additionally, noted that the Veteran was not diagnosed with Barrett's esophagus until 40 years after service in 1996. The Board acknowledges the Veteran's contentions that his esophageal conditions are related to exposure to contaminated water at Camp Lejeune. However, the Veteran's statements may not be used to establish a nexus opinion regarding these issues. The issues are medically complex, as they require knowledge of the interaction between multiple organ systems in the body. Therefore, it is outside the competence of the Veteran in this case. See Jandreau, 492 F.3d at 1377 n.4; see also Kahana, 24 Vet. App. at 435. As such, the Veteran's opinion lacks probative value, and an opinion by a qualified medical expert is required to decide the claims. Consequently, the Board gives more probative weight to the VA opinions described above. The Board finds the opinions to be persuasive, as they rely on expert knowledge and the Veteran's medical history. Nieves-Rodriguez, 22 Vet. App. at 304. The opinions support that the Veteran's esophageal condition is unrelated to his exposure to contaminated water at Camp Lejeune. In this regard, the opinions are consistent with one another in that they explain that the more likely etiology for the Veteran's esophageal condition are related to risk factors present in the case of the Veteran. In addition, there is no similar medical opinion of record weighing in favor of service connection. In reaching the conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, under the presumptive and direct theories of service connection, that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection is not warranted for an esophageal condition. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Gray, 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.