Citation Nr: 21030350 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 16-31 393 DATE: May 18, 2021 ORDER Entitlement to service connection for anemia, to include as secondary to service-connected duodenal ulcer is denied. FINDING OF FACT 1. Veteran received an in-service blood transfusion that was due to anemia associated with acute gastrointestinal bleeding. 2. Veteran's in-service anemia was acute and resolved in-service. 3. The Veteran has post-service microcytic anemia that did not have its onset in service or is otherwise attributable to service. 4. Veteran's post-service microcytic anemia is unrelated to the in-service anemia. 5. The Veteran's post-service microcytic anemia is unrelated (causation or aggravation) to a service-connected disease or injury. CONCLUSION OF LAW 1. The criteria for service connection for iron deficiency anemia and microcystic anemia are not met. 38 U.S.C. §§ 1110, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.306. 2. Anemia is not proximately due to or a result of or aggravated by a service-connected disease or injury. 38 C.F.R. §§ 3.303, 3.310. 3. Primary anemia was not incurred in or aggravated by service, nor may the disability be presumed to have incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1966 to April 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In November 2018, the Board remanded this case for further development. The November 2018 remand required that the VA schedule the Veteran for an examination to obtain an additional opinion. Accordingly, the Board's remand instructions have been substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for anemia, to include as secondary to service-connected disease or injury The Veteran contends that he has anemia that is due to his service. He alternatively contends that his anemia is secondary to his service-connected duodenal ulcer. Service connection has been granted for a duodenal ulcer and a related scar. Pertinent Legal Criteria Veterans are entitled to compensation from VA if they develop a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. § 1110 (wartime service). To establish a right to compensation for a present disability, a veteran must show: "(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"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). For certain chronic disease, including anemia, primary, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected unless clearly attributable to intercurrent causes. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. 3.303(b). The Board notes that the Veteran has not claimed that his disabilities on appeal are the result of combat with the enemy. Therefore, the combat provisions of 38 U.S.C. § 1154 are not for consideration. Service connection is warranted for disability which is proximately due to or the result of a service-connected disease or injury. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Any increase in severity of a non-service-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 or injury will be service connected. However, VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. Part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). For secondary service connection to be granted, generally there must be (1) evidence of a current disability; (2) evidence of a service-connected disease or injury; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a) (2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2019). Direct Service Connection On August 26, 1969 a medical note was created for Veteran when he reportedly passed out at work. The note stated that Veteran felt dizzy while sitting and had low blood pressure. Veteran was provided a consultation on August 28, 1969 referencing Veteran's previous medical note. The note stated that recent x-rays showed evidence of peptic ulcer disease. Veteran was admitted to the hospital with a hemoglobin level of 11.8. Veteran's hemoglobin level two days later was reported at 7.4. Veteran's stool was positive for occult blood. On August 29, 1969 the Veteran was admitted to a hospital due to upper gastrointestinal hemorrhage. Veteran's hematocrit level was 32 and hemoglobin level was 10.0. Veteran received two units of whole blood in the 24 hours prior to the admission and then received another unit of whole blood after admission. After receiving the one whole unit of blood Veteran's hematocrit level rose to 13.3 and hemoglobin level rose to 41 on September 4, 1969. During Veteran's visit he had received a blood transfusion along with receiving the units of blood. Veteran was diagnosed with chronic peptic ulcer disease and acute gastrointestinal hemorrhage that was secondary to the peptic ulcer disease. An addendum clinic record was made for Veteran for treatment from September 7 to September 11, 1969. The record stated that 24 hours before Veteran was to be discharged his hemoglobin level was at 36 and hematocrit level was at 12.0. The Veteran was kept in the hospital. On the September 10, Veteran's blood was measured again with hemoglobin level at 40 and hematocrit level at 13. It was noted that Veteran was asymptomatic throughout the treatment and had no further complications. Another medical note was created for Veteran on October 13, 1969. Veteran reported having recent gastrointestinal bleeding. Veteran's blood work showed his hemoglobin level at 15.2. On December 10, 1969, a blood test was provided to Veteran. Veteran's blood-gross and occult results were negative. Veteran's laboratory findings during the discharge examination noted that Veteran had a hematocrit level of 48. The Veteran's December 1969 discharge examination noted that Veteran was hospitalized for two days for recurrence symptoms of chest pains, dizziness, low blood pressure and spitting up blood associated with gastrointestinal difficulties. A consultation was attached to the discharge examination stating that in August 1969 Veteran was experiencing upper gastrointestinal hemorrhage that was presumably secondary to a duodenal peptic ulcer. The consultation noted that there was no other evidence of gastrointestinal bleeding after the Veteran's two day visit in the hospital. An antrectomy with vagotomy was performed on Veteran in March 1972. The examiner stated that Veteran's laboratory results were within normal limits except for hematocrit. The examiner stated that Veteran's hematocrit level was 35 and fell to 32, but was maintained at that level with efforts of 14 units of blood. The examiner stated that the operation was completed successfully and that his post-operative course was uncomplicated. In December 2008 Veteran's private provider diagnosed anemia microcytic. The note does not include any information except the Veteran's diagnosis. Veteran was provided a colonoscopy with epinephrine injection due to complaints of rectal bleeding in November 2012. Veteran was diagnosed with medium hemorrhoids and moderate pancolonic diverticulosis as a result of the examination. A January 2013 private outpatient note was made providing a list of Veteran's ongoing diagnosed problems. On the list the Veteran was diagnosed alpha thalassemia minor, microcytic anemia, and iron deficiency anemia. The note did not provide any rationale or date on these diagnoses. In April 2014 Veteran was provided laboratory blood test results. The results stated that Veteran's hemoglobin level was 13.9 and hematocrit level was 43.8. The laboratory indicated that these results were within the normal range for Veteran. The Veteran's MCV (mean corpuscular volume), MCH (mean corpuscular hemoglobin) and MCHC (mean corpuscular hemoglobin concentration) levels were the only ones considered out of range and lower than normal. Veteran was provided a VA examination and disability benefits questionnaire in May 2016. During the examination a sample of Veteran's blood was taken for examination. The Veteran's hemoglobin level was 14.5, hematocrit level was 45.2, white blood cell level at 4.4 and platelets level at 218. The examiner noted that Veteran's hemoglobin and hematocrit levels were stable and not indicative of anemia or bleeding. The Veteran's blood was taken and tested on November 2019. The Veteran's hemoglobin level was at 13.6 and hematocrit level was at 42. Both these levels were considered within normal range for Veteran. Primary Anemia The Board notes that there are multiple forms of anemia. There is primary anemia and secondary anemia which is a milder anemia that be caused by a variety of different factors. The statutory chronic disease version of anemia is primary anemia which the Veteran did not have in service. While Veteran's hemoglobin levels dropped which required an in-service blood transfusion, this transfusion was associated with the gastrointestinal bleeding. The only time that Veteran's hemoglobin levels were reported lower than normal was when he experienced gastrointestinal bleeding. There were no other complaints or reports of low hemoglobin or hematocrit levels associated with Veteran in-service. The Board notes that once Veteran's gastrointestinal bleeding stopped, so did any symptoms of anemia. The anemia that Veteran experienced was acute and resolved in-service. This is at odds with the chronic nature of primary anemia. The records only recording low hemoglobin levels during gastrointestinal bleeding are highly probative. The primary anemia that Veteran may be diagnosed with is not associated with any of the gastrointestinal bleeding since it was acute. The anemia Veteran did experience resolved in-service and was associated only with gastrointestinal bleeding. The Board notes that Veteran may now have primary anemia, but it was not manifest during service or within one year of separation. The record is silent of any complaints or blood tests after service until a surgery Veteran had in 1972. While the surgery was unrelated to the Veteran's disabilities a blood test was taken. The Veteran's blood showed normal levels of hemoglobin and hematocrit. Further there was no continuity of symptomology. The Veteran's post-service medical records are silent of any low hemoglobin levels and any diagnosis until 2008. The silence of the records combined with the report of normal hemoglobin levels during the late surgery provide great probative weight against any claim that anemia developed within one year of separation. There was no manifestation of primary anemia within one year of separation. While Veteran may now be diagnosed with primary anemia, the preponderance of evidence is against the Veteran's claim for a direct service connection of the chronic disease primary anemia. The anemia that he had in service resolved and the medical evidence establishes that the post-service anemia is unrelated to the inservice acute anemia. Secondary Anemia Associated with Gastrointestinal Bleeding Secondary Service Connection As stated above, the Veteran was diagnosed with anemia microcytic on a December 2008 private outpatient note. A January 2013 private medical visit note was created which included microcytic anemia as well as included alpha thalassemia minor and iron deficiency anemia to the list of Veteran's ongoing health problems. In October 2019, a VA examination was provided to the Veteran. The Veteran was diagnosed with iron deficiency anemia, alpha thalassemia minor and microcytic anemia. The examiner opined that Veteran's anemia was less likely than not proximately due to the result of Veteran's service-connected condition. The examiner explained that the two conditions were not medically related and that the Veteran's duodenal ulcer resolved during Veteran's active duty. The upper endoscopy performed on June 2016 showed no duodenal ulcer, no active bleeding and mild gastroesophageal reflux disease. The examiner stated that Veteran's current iron deficiency anemia and microcytic anemia are related to Alpha Thalassemia Minor. The examiner explained that Alpha Thalassemia is a blood disorder that reduces the production of hemoglobin which in turn caused the anemias specifically microcytic anemia and iron deficiency anemia. Therefore, there is no nexus established between Veteran's duodenal ulcer and diagnosed anemias. The examiner opined that the Veteran's claimed condition was not at least as likely as not aggravated beyond its natural progression by the service-connected condition. The examiner explained that the Veteran's anemias are related to the diagnosed condition of Alpha Thalassemia Minor, not the duodenal ulcer. The examiner explained that Thalassemia is a blood disorder that is inherited and passed down by the person's parents which can cause ongoing mild or severe anemia. The Board notes that while Veteran was previously diagnosed with a duodenal ulcer, the Veteran's anemias are rather related to his inherited blood disorder. The in-service duodenal ulcer no longer exists and was reportedly resolved during the June 2016 endoscopy. The examiner stated that the ulcer resolved before the Veteran's active duty was resolved as well. The Board has carefully evaluated the evidence and finds that a preponderance of the competent and probative evidence of record is against a finding that the Veteran's iron deficiency anemia and microcytic anemia are due to or aggravated by his duodenal ulcer or any service connected disease or injury and service connection is therefore not warranted on a secondary basis. Here the preponderance of the evidence is against the claims and there is no doubt to be resolved. Conclusion The evidence establishes that the appellant had a bleed during active service and required transfusions. However, the bleeds ended and the blood tests returned to a normal range. Post service, medical evidence establishes that he developed a different type of anemia that was unrelated to the in0serviuce findings and unrelated (causation or aggravation) to a service connected disease or injury. The preponderance of the evidence is against the claim and there is no doubt to be resolved. H. N. SCHWARTZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Konieczny, Adam 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.