Citation Nr: 21042541 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 17-10 713A DATE: July 13, 2021 ORDER Service connection for a gastrointestinal disability as secondary to service-connected bronchial asthma and/or rhinitis is denied. VETERAN'S CONTENTIONS The Veteran contends that his gastrointestinal disability was caused or aggravated by his service-connected bronchial asthma and/or rhinitis and/or related medications. FINDING OF FACT The Veteran is not shown to have a gastrointestinal disability that had its clinical onset in active service, manifested within one year of his discharge from active service, or that is otherwise related to his period of active service, to include as secondary to service-connected bronchial asthma and/or rhinitis and/or related medications. CONCLUSION OF LAW The criteria for service connection for a gastrointestinal disability are not met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. §§ 3.303, 3.310, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1964 to June 1967. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a November 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. This claim was previously before the Board in January 2019, at which time the Board remanded it for additional development. Entitlement to service connection for a gastrointestinal disability as secondary to service-connected bronchial asthma and/or rhinitis Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Further, service connection may be established on a secondary basis for a disability which was either caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical evidence. VA must also consider all favorable lay evidence of record. See 38 U.S.C. § 5107(b); see also Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (a Veteran is competent to report on that of which he or she has actually observed and is within the realm of his or her personal knowledge). Here, in addressing the criterion of a current disability, VA treatment records confirm a current diagnosis of gastroesophageal reflux disease (GERD). See November 2015 Lowell OPC Records. In addressing in-service incurrence, as noted above, the Veteran has alleged that he has a gastrointestinal disability secondary to service-connected bronchial asthma and/or rhinitis and/or related medications. The Veteran's service treatment records (STRs) are void of diagnosis of or treatment for any gastrointestinal disability. In addressing nexus, to the extent that the Veteran has stated that he has a gastrointestinal disability attributable to service, the Board finds that he is competent to report on his symptoms and that of which he has personal knowledge, but he is not competent to provide an opinion as to the etiology of his disability because such a question is not answerable by the application of knowledge within the realm of a lay person. See Layno, 6 Vet. App. at 469-70; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Here, because the etiology of the gastrointestinal disability may be multifactorial, and he lacks the requisite expertise, he is not competent to offer an opinion as to a relationship to service. The evidence of record otherwise includes a May 2017 VA opinion that concluded that the condition claimed was less likely than not proximately due to or the result of the Veteran's service-connected condition. The examiner reasoned that GERD is multifactorial in origin and is highly prevalent in the population. The examiner determined that the Veteran's greatest risk factors for GERD were obesity and age (over 40). The Veteran's height of 66 inches and weight of 196 pounds resulted in a BMI of 31, which classifies as obese, and the Veteran is 70 years old. The examiner further reasoned that GERD precedes and causes or exacerbates asthma, rather than the other way around, because the acidic gastric secretions irritate the respiratory airways. Although beta-agonists (e.g., Albuterol) can transiently relax the esophageal sphincter, so also can certain foods (coffee, alcohol, chocolate, fatty meals), medications (nitrates, calcium channel blockers, anticholinergics), hormones (e.g. progesterone), and nicotine. The reference article, in fact, cites the western diet as the primary cause for the increase in prevalence of GERD. Therefore, the examiner concluded that it was not possible to state that the Veteran's asthma and asthma medications caused his GERD. In January 2019 the Board remanded the Veteran's claim to obtain an addendum opinion addressing aggravation and rhinitis. In a November 2019 addendum, an examiner opined that it was less likely than not that the Veteran's GERD was proximately due to his service-connected asthma, to include medications. The examiner reasoned that the Cleveland Clinic article associating GERD with asthma did not contain original research, nor did it contain data in support of its contentions. The examiner noted that the article contained the assertion that "asthma and some asthma medications may in turn worsen GERD symptoms". The examiner explained, however, that the article did not fully acknowledge the speculative nature of that assertion, and that any worsening of symptoms is not likely to be major nor alter the course of GERD. A previous examiner pointed out that several inhaled asthma medications, including medication taken by the Veteran, can cause a temporary relaxation of the lower esophageal sphincter. A more potent medication for this side effect, which the Veteran does not take is theophylline. Even in that case, any worsening would most likely be symptomatic and not structural. The examiner also opined that it was less likely than not that the Veteran's GERD was aggravated by his service-connected asthma, to include medications. The examiner reasoned that it is within the realm of medical plausibility that the Veteran's inhaled asthma medications cause a temporary relaxation of the lower esophageal sphincter (LES) and a temporary worsening of symptoms. It was not plausible, however, that persistent LES relaxation occurred and therefore not plausible that alteration of the course of the disease occurred. The examiner further opined that it was less likely than not that the Veteran's GERD was proximately due to or aggravated by his service-connected rhinitis, to include medications. The examiner reasoned that there was no convincing mechanism by which rhinitis would cause or aggravate GERD. Sympathomimetic medications used to treat rhinitis could also cause temporary relaxation of the LES but invoking causality could be no more than speculative. The Board finds the May 2017 and November 2019 VA examiner opinions to be highly probative. The opinions were based on a review of the claims file, relevant facts, and peer reviewed medical literature, and the examiners provided a detailed rationale. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). There is no competent evidence to the contrary. The Board notes that the February 2013 opinion from Dr. HK referenced by the Veteran fails to opine that the Veteran's GERD was caused or aggravated by his service-connected bronchial asthma and/or rhinitis and/or related medications. In fact, it states that the reverse is true (asthmatic symptoms are partially due to acid reflux). In sum, without any competent evidence that the Veteran has a gastrointestinal disability related to service, direct service connection is not warranted. Additionally, there is no indication that the condition manifested within one year of service. The Board finds that the Veteran's gastrointestinal disability did not have its clinical onset in service, or within one year of his discharge from active service and is not otherwise related to a period of active service; therefore, service connection is not warranted. There is no doubt to be resolved in this case. 38 U.S.C. § 5107. S.C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Smith-Jennings, 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.