Citation Nr: 21030366 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 15-10 224A DATE: May 18, 2021 ORDER Entitlement to service connection for a digestive disorder other than irritable bowel syndrome and hemorrhoids, to include hematochezia and duodenitis is denied. Entitlement to service connection for gastritis is denied. FINDINGS OF FACT 1. The preponderance of the evidence of record weighs against finding that the Veteran has a digestive disorder other than irritable bowel syndrome and hemorrhoids, to include hematochezia and duodenitis as casually related to an in-service injury, event, or disease, or as secondarily related to service-connected disabilities. 2. The preponderance of the evidence of record weighs against finding that the Veteran has a current diagnosis of gastritis as casually related to an in-service injury, event, or disease, or as secondarily related to service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for a digestive disorder other than irritable bowel syndrome and hemorrhoids, to include hematochezia and duodenitis have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). 2. The criteria for establishing entitlement to service connection for gastritis have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Air Force from December 1987 to July 2011. Pursuant to a July 2019 Board decision, this matter was remanded for additional development to include scheduling the Veteran for a new VA examination. As the requested development is now complete, this matter has been returned to the Board for appellate consideration. Duty to Assist and to Notify VA is required to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2020). Copies of compliant VCAA notices were located in the claim's file. VA's duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. Peters v. Brown, 6 Vet. App. 540, 542 (1994). In this case, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Thus, upon careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service connection, generally Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C. § 1110, 1131 (2012); 38 C.F.R. §§ 3.303 (a), 3.304 (2020). Entitlement to service connection benefits is established when the following elements are satisfied: (1) the existence of 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 disease or injury incurred or aggravated during service (the medical 'nexus' requirement). See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303 (a) (2020). Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) and (b) (2020). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; 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). Furthermore, 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 (2012); 38 C.F.R. § 3.102 (2020); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the Veteran. Id. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant). Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue. 1. Entitlement to service connection for a digestive disorder other than irritable bowel syndrome and hemorrhoids, to include hematochezia and duodenitis The Veteran seeks to establish service connection for a digestive disorder other than irritable bowel syndrome and hemorrhoids, to include hematochezia and duodenitis. As discussed in more detail below, the preponderance of the evidence is against his claim. In analyzing the Veteran's claim, the threshold inquiry before 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 Veteran received treatment for IBS with chronic diarrhea, the preponderance of the evidence is against finding that he suffers from a separate and distinct digestive disorder that began during active service, or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a), (d). Service treatment records confirm treatment for IBS with chronic diarrhea. No other gastrointestinal conditions were documented during active service. Post-service treatment records document gastritis, duodenitis, and IBS following an upper endoscopy on or about March 2004. In January 2009, the Veteran was treated for hematochezia. Reportedly, he experienced anal blood loss with bowel movements that filled the bowl. Again, in August 2010, a health record noted treatment for acute gastroenteritis. During the clinical interview, the Veteran reported a 20-year history of increased frequency of bowel movements with intermittent bloody stools. In October 2010, a colonoscopy revealed normal findings. One year later, the Veteran reported occasional bouts with significant bleeding during bowel movements in October 2011. On examination in October 2013, the Veteran was afforded a VA examination. The examiner concluded current diagnoses of gastritis and duodenitis were not warranted. In support of the stated conclusion, it was explained that the Veteran was diagnosed with gastritis and duodenitis in 2004; however, the conditions were deemed acute and transitory as gastritis results from inflammation of the lining of the stomach. Typical causes of acute symptomology include alcohol consumption and prolonged use of nonsteroidal anti-inflammatory drugs. The Veteran's experience of diarrhea was associated with his service-connected IBS and his melena with his service-connected hemorrhoids. Therefore, his current symptoms were deemed unlikely related to his diagnosis of gastritis or duodenitis in 2004. Thereafter, in January 2014, esophagogastroduodenoscopies (EGD) revealed a duodenal ulcer, gastritis, a hiatal hernia, colon ulcerations, and internal hemorrhoids. In February 2014, A VA examination regarding his service-connected hemorrhoids noted small amounts of blood with bowel movements. The examiner did not diagnose hematochezia and stated that the red blood in the Veteran's stool likely resulted from hemorrhoids. In March 2014, a VA treatment record noted the Veteran's complaint of bright red blood around the rectum over the past six years. After onset, bleeding persisted for two to three days, then resolved with complete remission for approximately one month. No cause for the bleeding was found in spite of recent colonoscopies. The diagnostic impression listed hematochezia. The bleeding was deemed likely related to hemorrhoids and frequent bowel movements. On examination in October 2013, current diagnoses included gastritis and duodenitis. During the clinical interview, the Veteran reported a history of EGD in 2004 with a current diagnosis of gastritis and duodenitis and a colonoscopy the same year confirmed a diagnosis with IBS. Frequent and prolonged trips to the bathroom were reported, with diarrhea and blood in stool. Other symptoms include hemorrhoids and pain in the right side. After consuming food, the Veteran reported pain for up to two hours. Use of oral medications caused an upset stomach and worsening diarrhea. Following treatment for chronic IBS-related symptoms in September 2013, the Veteran was referred to a gastroenterologist. Continuous medications were not required to manage the Veteran's condition. Recurring episodes of the Veteran's stomach condition occurs 4 or more times per year. Bouts with abdominal pain, vomiting, and melena was noted. The Veteran's abdominal pain recurs periodically, vomiting persists for less than 1 day after onset, and his melena for 1-9 days. No incapacitating episodes were reported. Other pertinent physical conditions indicated that the abdomen was soft, nontender, with no hepatosplenomegaly. The aorta was described as non-palpable. An upper endoscopy in 2004 revealed gastritis and duodenitis; a colonoscopy showed IBS. The same year, a computerized tomography (CT) scan was unremarkable. No other significant diagnostic findings were indicated. A functional impact was described as frequent/prolonged trips to the bathroom that impair his ability to work. Following the clinical evaluation, the examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran's condition was incurred in or caused by an in-service injury, event, or disease. In support of the stated conclusion the examiner noted that the Veteran was treated for symptoms related to IBS, including diarrhea, melena, and hemorrhoids in January 2007. An acute onset of gastritis and duodenitis was noted in 2004. Gastritis causes transitory inflammation of the lining of the stomach. The main acute causes are excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs (also known as NSAIDs). During the current examination, the examiner found no evidence that the Veteran suffers from gastritis or duodenitis. Only symptoms of diarrhea from IBS and melena from hemorrhoids were indicated. H. pylori testing was negative; however, occult blood testing positive. Therefore, the veteran does not currently have gastritis or duodenitis and his current symptoms are less likely than not caused from his diagnosis of gastritis or duodenitis in 2004 from EGD testing. In May 2018, a CT scan of the abdomen and pelvis revealed a possible tiny 5-millimeter (mm) cyst in the anterior aspect of the mid right kidney, with no evidence of obstruction and a mildly thickened second portion of the duodenum with nonspecific duodenitis. Pursuant to a July 2019 remand decision, the Veteran's claim was remanded for a new examination. Specifically, the Board noted that the October 2013 VA medical opinion was based, at least in part, on the examiner's finding that the Veteran did not have a current diagnosis of gastritis or duodenitis. However, subsequent medical records include diagnoses of gastritis, a duodenal ulcer, and other digestive disorders. In addition, the Veteran's military personnel records show a period of service in Qatar from June 2010 to September 2010. As the Veteran is a Persian Gulf Veteran, an additional examination was deemed necessary to determine if his symptoms were manifestations of an undiagnosed illness or of a medically unexplained chronic multi-symptom illness. Accordingly, the Veteran underwent a new VA examination in June 2019. A current diagnosis of IBS was indicated. During the clinical interview, the Veteran reported eating food while stationed in New Mexico in 1988 that caused him to become ill. His symptoms included diarrhea, frequent bowel movements, and prolonged trips to the bathing. Specifically, he reported spending 6-12 hours in the bathroom per day. Prescribed treatments include oral medication, Dicyclomine. No symptom improvement was indicated. Other signs and symptoms included watery stools, alternating explosive diarrhea and constipation. Episodes of bowel disturbance with abdominal distress on a more or less constant basis. No unexplained weight loss was indicated. No other pertinent physical findings were identified. In January 2014, a colonoscopy revealed two transverse colon ulcers and duodenal ulcer. The Veteran described a functional impact as an inability to work due to frequent abdominal pain with bloody stools and diarrhea multiple times per day. The noted symptomology impacts both physical and sedentary forms of employment as he is required to spend significant periods of time in the bathroom. Frequent absences and impaired productivity were reported. In a medical opinion, dated January 2020, the examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran suffers from gastritis that was incurred in or otherwise caused by an in-service injury, event, or illness. In support of the stated conclusion, the examiner noted that there is no evidence of a current diagnosis of gastritis. A recent EGD showed normal gastric mucosa, with no evidence of gastritis. Gastritis is an acute and transitory condition, although the record confirms a prior diagnosis there is no medical evidence of the condition at this time. Similarly, the examiner opined that the Veteran's previous diagnosis of acute gastritis is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected IBS. In support of the stated conclusion, the examiner noted that there is no medical link between gastritis and IBS. IBS is a chronic functional disorder of the gastrointestinal tract characterized by chronic abdominal pain and altered bowel habits in the absence of an organic disease. This affects the intestines not the stomach lining. Common symptoms include recurrent abdominal pain at least once day per week, over the previous three-month period with two or more of the following: defecation with an associated change in frequency, form, or appearance of stool. Gastric inflammatory disease can be broadly categorized into gastritis and gastropathy based on the presence of associated mucosal inflammation due to gastric injury. Gastritis is predominantly an inflammatory process, while the term gastropathy denotes a gastric mucosal disorder with minimal to no inflammation. Although the term "gastritis" is often used to describe endoscopic or radiologic characteristics of abnormal-appearing gastric mucosa, a diagnosis of gastritis requires histopathologic evidence of inflammation. This is a stand-alone disease of the gastric lining and is not related to his bowels or hemorrhoids. Hemorrhoids are collections of submucosal, fibrovascular, arteriovenous sinusoids that are part of the normal anorectum not part of the stomach or stomach lining. There is no link between gastritis and hemorrhoids. The examiner also considered whether it is at least as likely as not (50 percent probability or greater) that the Veteran's digestive disorder was caused or aggravated by his service-connected irritable bowel syndrome and hemorrhoids, to include the medication used to treat such disorders. Following a review of the record, the examiner concluded that no additional diagnosis of a digestive disorder was warranted, therefore, no aggravation was found. At the present time, the only current GI diagnosis warranted is IBS. Based upon the foregoing, the Board finds that the preponderance of evidence is against the Veteran's claim of entitlement to service connection for a digestive disorder other than irritable bowel syndrome and hemorrhoids, to include hematochezia and duodenitis. While the evidence of record reveals treatment for an acute diagnosis of gastritis and duodenitis, recent VA examinations with supportive diagnostic testing found no medical linkage between the listed conditions and active service, to include as secondary to the Veteran's service-connected disabilities or aggravation. The Board acknowledges the Veteran's complaints of gastrointestinal symptoms in service; however, the record confirms a grant of service connection for IBS. Moreover, post-service treatment records show treatment for an acute onset of gastritis and duodenitis. At no time has the medical evidence suggested a "nexus" between the noted diagnoses and active service, to include as secondary to the Veteran's service-connected disabilities nor aggravation related thereto. While the Board acknowledges that the Veteran's competence to report on observable symptoms, he is not competent to analyze complex medical questions to include assessments of the nature and etiology of the symptoms or render "nexus" opinions in the absence of relevant training and medical expertise. Layno v. Brown, 6 Vet. App. 465, 470 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377. In light of the findings stated above, the Board concludes that service connection is not warranted for a digestive disorder other than irritable bowel syndrome and hemorrhoids, to include hematochezia and duodenitis. As the preponderance of the evidence is against the Veteran's claim, there is no reasonable doubt to be resolved, and the claim must be denied. 38 U.S.C. § 5107 (b) (2012); 38 C.F.R. § 3.102 (2020); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for gastritis The Veteran contends that he is entitled to service connection for gastritis, as causally related to active service. As discussed in more detail below, the preponderance of the evidence is against his claim. As a preliminary matter, the Board incorporates by reference, the procedural arguments identified in Section 2. Service treatment records show that the Veteran was diagnosed with IBS and chronic diarrhea during active. Post-service, he was treated for an acute onset of gastritis in 2004 and again, in 2010. In this case, the Veteran has been afforded multiple VA examinations. At no time, has the medical evidence revealed an etiological linkage between an acute onset of gastritis and active service. In a January 2020 medical opinion, the VA examiner concluded that it is less likely than not (less than 50 percent probability) that the Veteran's previous diagnosis of acute gastritis is causally related to active service, to include as secondary to his service-connected IBS and hemorrhoids. In support of the stated conclusion, the examiner noted that gastric inflammatory disease can be broadly categorized into gastritis and gastropathy based on the presence of associated mucosal inflammation due to gastric injury. Gastritis is predominantly an inflammatory process, while the term gastropathy denotes a gastric mucosal disorder with minimal to no inflammation. Although the term "gastritis" is often used to describe endoscopic or radiologic characteristics of abnormal-appearing gastric mucosa, a diagnosis of gastritis requires histopathologic evidence of inflammation. Conversely, IBS is a chronic functional disorder of the gastrointestinal tract characterized by chronic abdominal pain and altered bowel habits in the absence of an organic disease. This affects the intestines not the stomach lining. Common symptoms include recurrent abdominal pain at least once day per week, over the previous three-month period with two or more of the following: defecation with associated change in frequency, form, and appearance of stool. There is no medical link between gastritis and IBS. In making all determinations, the Board has fully considered all medical evidence and lay assertions of record. While the Board recognizes the Veteran's subjective belief that his acute gastritis was caused by or otherwise related to active service, to include as secondary to his service-connected disabilities, the medical evidence does not support his contentions. Furthermore, the record is silent for any evidence that the Veteran possesses the requisite training or expertise to offer a complex medical opinion, to include linking gastritis to active service, to include as secondary to service-connected IBS. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for gastritis, to include as secondary to his service-connected IBS must be denied. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Whitaker, 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.