Citation Nr: 22018391 Decision Date: 03/29/22 Archive Date: 03/29/22 DOCKET NO. 17-37 950 AlexisDATE: March 29, 2022 ORDER Service connection for gastroesophageal reflux disease (GERD) is denied. FINDING OF FACT The Veteran's GERD was not caused by or incurred during service, and is not otherwise related to active service. CONCLUSION OF LAW The criteria for service connection for GERD have not been met. 38 U.S.C. §§ 1101, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1987 to September 1991, including in southwest Asia during the Persian Gulf War. This case is before the Board of Veterans' Appeals (Board) on appeal from a September 2014 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In that rating decision, the RO denied entitlement to service connection for GERD. The Veteran's notice of disagreement (NOD) was received in December 2014. The RO issued the statement of the case (SOC) in July 2017, and the Veteran's VA Form 9, substantive appeal was received in July 2017. In March 2020, the Board remanded the case for further development and adjudicative action. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for a claimed disability may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service-connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a). For veterans with service in the Southwest Asia theater of operations during the Persian Gulf War, service connection may be established under 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Under this law and regulation, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of "a qualifying chronic disability" that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317, qualifying chronic disabilities include, among other things, an undiagnosed illness and a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317(a)(2). Signs or symptoms that may be manifestations of an undiagnosed illness or a medically unexplained chronic multisymptom illness include, but are not limited to, fatigue. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a), (b). 1. Entitlement to service connection for GERD The Veteran contends that he is entitled to service connection for GERD, which contends began in-service. Specifically, he has variously asserted that the GERD began during service, to include as a result of taking pyridostigmine bromide blister packs during service, and has continued since then. See February 2015 Correspondence from Veteran. Initially, though the Veteran served in southwest Asia during the Persian Gulf War, GERD is not considered a medically unexplained chronic multi symptom illness (MUCMI) under 38 C.F.R. § 3.317, and therefore, the question of presumptive service connection under 38 C.F.R. § 3.317 is not at issue in this case. See Atencio v. O'Rourke, 30 Vet. App. 74 (2018). Nonetheless, service connection may still be warranted on a direct basis. Service treatment records (STRs) include a July 1987 Report of Medical History which shows no history of any gastrointestinal problems, or GERD, and a July 1987 Report of Medical Examination which was normal without any indication of gastrointestinal issues. In November 1987, the Veteran reported that he was in good health and specifically denied any history of stomach or intestinal trouble. STRs from January 1989 show that the Veteran was treated for complaints of diarrhea. He felt nauseated and hot, and reported vomiting, weakness, and loss of appetite. The examining clinician noted hyperactive bowel sounds in the right abdominal area. The Veteran was assessed with acute viral gastroenteritis. April 1991 STRs show that the Veteran was treated for complaints of nausea and vomiting, lasting three days. He was assessed with gastroenteritis. At the Veteran's separation examination in July 1991, he denied any current medical conditions, and reported that he was in "good health." He specifically denied any history of frequent indigestion, stomach trouble or intestinal trouble. A January 2007 private chest pain evaluation note shows that the Veteran denied a history of GERD or peptic ulcer disease (PUD). Social Security Administration office visit notes from August 2012 to June 2013 show that the Veteran denied any abdominal pain or nausea. No gastrointestinal diagnoses were rendered. In February 2015 correspondence, the Veteran reported the following: I believe [GERD] was caused from taking pyridostigmine Bromide "PB" blister packs during my service in Operation Desert Storm. I've had problems with this for the past 25 years. The Veteran was first diagnosed with GERD at a February 2021 VA esophageal conditions examination. The diagnosis was rendered based on the results of complete blood count (CBC) testing. The examiner noted the Veteran's history of the GERD as follows: He states that it doesn't seem to matter what he eats nothing will affect his symptoms. Veteran stated he began with pain in 2005 right lower rib. He had his gall bladder removed in 2015 which did not improve his symptoms. He has symptoms daily with a right lower rib aching. Usually occurs in the evening. He can sleep. He complains of symptoms after he eats and evening of bloating and gas. and acid and burning in his throat. He takes gas ex PRN which seems to help. [sic] The examiner further noted symptoms of infrequent episodes of epigastric distress, pyrosis (heartburn), and substernal pain. No nausea or vomiting was reported. The examiner opined that the GERD was less likely than not related to service. In forming the opinion, the examiner reviewed the medical records, including STRs, and performed the in-person examination. The examiner noted the documented episode gastroenteritis in-service, without further episodes or any epigastric diagnosis rendered. The examiner cited the February 1991 separation examination report in which the Veteran denied any abdominal or gastrointestinal symptoms. The examiner noted that the Veteran's current symptoms were right-sided rib pain and gas, as well as "some burning" in the esophagus. The examiner noted the absence of any endoscopic testing records, and noted that the Veteran never underwent any specific treatment for GERD, such as a proton pump inhibitor (PPI). The examiner found that the STRs did not demonstrate the presence of a chronic pattern of illness. Further, the examiner noted that the Veteran's current symptoms of right lower rib pain "may or may not" be related to GERD, as that area is not a typical area of epigastric distress. The examiner cited to medical literature when discussing common GERD symptoms, such as chest pain and burning in the chest at night, as well as aggravating factors, such as drinking coffee, smoking, and eating large meals. Based on this evidence, the analysis turns to whether the Veteran's GERD is related to service. The February 2021 VA examiner provided the sole medical opinion on that issue. The examiner reviewed the entire claims file, to include the Veteran's STRs, the post-service treatment records, and the Veteran's lay statements regarding the history of the disease. The examiner conducted an in-person examination of the Veteran, at which examination the Veteran was given the opportunity to further describe his observations concerning the history of his GERD. After reviewing the medical and lay evidence, and conducting the in-person examination with the Veteran, the examiner consulted the medical literature in order to form a fully informed opinion. The examiner's opinion is based upon an accurate factual basis, which includes a thorough understanding of the Veteran's GERD disability picture and history. The examiner's rationale in support of the opinion is clearly worded, as to be unequivocal. For those reasons, the opinion carries substantial probative value. On the other hand, the Veteran certainly appears sincere in his belief that the GERD is related to service. The STRs show that the Veteran was assessed with gastroenteritis on two occasions during service. Symptoms were noted to include nausea and vomiting. In his February 2015 correspondence, the Veteran asserted "problems" with GERD for "25 years." At the VA examination, his symptoms included pain in the right substernal area, gas, infrequent epigastric distress, and heartburn. While the Veteran believes that his current GERD symptoms are related to service, the record does not show that he has the requisite medical expertise to provide such an opinion, because the issue is complex in nature and requires specialized medical expertise, training, and skills. In essence, while the Veteran is competent to describe his observations as to the onset and frequency of symptoms, he is not competent to opine that the two isolated assessments of gastroenteritis in-service are related to his current GERD, which was first diagnosed in February 2021. As a result, the Veteran's lay belief that a link exists which would satisfy the "nexus" requirement of the service connection claim carries no probative value. Moreover, the Veteran's descriptions of the symptoms in the February 2015 letter conflict with his statements made during medical examinations in-service, as well as to the February 2021 VA examiner. As set out above, the Veteran reported that he was in good health at his July 1991 separation examination; he did not report any current symptoms related to GERD, and he specifically denied having frequent indigestion, stomach trouble, or intestinal trouble. In the February 2015 letter, he reported having had GERD issues for the previous 25 years, since approximately 1990, but did not explain what those symptoms were. The symptoms that he reported at the February 2021 examination had not been previously reported; and, he reported that those symptoms had a different onsetapproximately 2005. (Continued on the next page) In light of the above, the Board affords more probative value to the February 2021 VA examiner's opinion. As a result, the weight of the probative evidence in the record is against finding that the Veteran's GERD is related to service. There is no reasonable doubt to resolve in the Veteran's favor, and as a result, the claim must be denied. ALEXIS M. PARRISH Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. KAYS HUKILL 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.