Citation Nr: 22052051 Decision Date: 09/13/22 Archive Date: 09/13/22 DOCKET NO. 16-44 702 DATE: September 13, 2022 ORDER Entitlement to a 20 percent rating, for the entire appeal period, for service connected hemorrhoids is granted. Entitlement to a compensable rating for service connected residuals of anal fissurectomy is denied. REMANDED Entitlement to service connection for a gastrointestinal condition, to include diverticulosis and ulcerative colitis, is remanded. FINDINGS OF FACT 1. For the entire appeal period, the Veteran's hemorrhoid condition has been characterized by recurrent internal and external hemorrhoids, with persistent bleeding that led to the development of anemia. 2. The competent medical evidence of record does not show the Veteran currently experiences any anal fissures or any residuals of the fissurectomy that would warrant a compensable rating. CONCLUSIONS OF LAW 1. The criteria for a 20 percent for service connected hemorrhoids have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, DC 7336. 2. The criteria for a compensable rating for service connected residuals of anal fissurectomy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, DC 7330. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the U.S. Navy from September 1972 to September 1975. He testified at a Board hearing in September 2021 before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. The Board remanded the appeal in January 2022 to schedule the Veteran for a VA examination, which was completed in March 2022. INCREASED RATING Disability ratings are determined by the application of VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. The determination of whether an increased rating is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999). 1. Entitlement to a compensable rating prior to February 23, 2022, and higher than 20 percent thereafter for service connected hemorrhoids. The Veteran contends that his hemorrhoids and symptoms related to this condition are worse than the currently assigned rating. Under Diagnostic Code 7336, external or internal hemorrhoids are assigned a zero percent rating when they are mild or moderate, a 10 percent rating when they are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences, and a 20 percent rating when they are accompanied by persistent bleeding and with secondary anemia, or with fissures. Treatment records show the Veteran has suffered from chronic hemorrhoids since service. Multiple examinations showed internal and external hemorrhoids ranging in size. Records show a history of recurrent blood loss that have been attributed to hemorrhoids. In approximately November 2012, the Veteran was hospitalized for a GI bleed and decreased hemoglobin of 5.7. Hemorrhoidal banding was performed, and the bleeding ceased for some time. In December 2016, the Veteran was admitted to the hospital once more for a lower GI bleed from an unknown source that was the cause of significant anemia. A colonoscopy conducted as part of his treatment showed several internal hemorrhoids, which were found to be the cause of the rectal bleeding. In December 2017, the Veteran continued to report occasional bleeding when straining to use the bathroom. Another diagnostic colonoscopy conducted in 2017 noted large, external hemorrhoids, causing rectal bleeding. Statements submitted in support of the Veteran's claim from his children, friends and wife were submitted in March 2015 and October 2019. Each person indicated the recalled the Veteran having "bleeding episodes" and having to remain in the bathroom or go lay down due to associated headaches from the blood loss. During the September 2021 Board hearing, the Veteran testified that his hemorrhoid condition was well controlled and maintained by suppositories and a high fiber diet. In a September 2021 statement, the Veteran described almost dying from blood loss in 2013 and 2016. He underwent a hemorrhoidectomy and began taking better care of his condition through topical creams, wipes, suppositories, iron pills, and use of a toilet apparatus. He followed a healthy diet and took an assortment of vitamins to support his body function. During the December 2013 VA rectum and anus conditions examination showed hemorrhoids and a residual scar from an anal fissurectomy. The Veteran described recurring external hemorrhoids and bleeding. Physical examination showed a small, external hemorrhoid with no additional symptoms. The March 2014 VA examination report indicated there was no change from the December 2013 examination. The February 2022 VA examination noted mild to moderate, internal and external hemorrhoids, accompanied by persistent bleeding. The March 2022 VA examination showed the Veteran continued to experienced hemorrhoids and related symptoms and had a continuous treatment plan of suppositories. The examiner found that his hemorrhoids were mild or moderate with persistent bleeding. Physical examination showed small or moderate external hemorrhoids. Based on the foregoing, the Board finds that a 20 percent rating for the Veteran's hemorrhoid condition is warranted for the entire appeal period. Treatment records and the Veteran's statements confirm that he experienced recurrent hemorrhoids with persistent bleeding and anemia for several years prior to the February 23, 2022 award of a 20 percent rating. Based on available medical evidence, his condition met applicable criteria as early as 2012. The Veteran has also reported experiencing increased bleeding and decreased hemoglobin levels as early as 2013. Therefore, a 20 percent rating for hemorrhoids is warranted for the entire appeal period. As previously discussed, a 20 percent rating is the maximum rating assignable for the Veteran's hemorrhoid disability. Accordingly, an increased schedular rating higher than 20 percent is not available. Id. 2. Entitlement to a compensable rating for service connected residuals of anal fissurectomy. The Veteran contends that he continues to experience residuals of an anal fissurectomy. Specifically, he noted that he has had ongoing bleeding since surgery and underwent a blood transfusion in 2016. His condition was previously rated under Diagnostic Code 7332 for impairment of sphincter control. Records confirm diagnosis of fissures during service and fissurectomy in 1979. Since that time, records show the reoccurrence of hemorrhoids and anal bleeding. During the December 2013 VA rectum and anus conditions examination showed hemorrhoids and a residual scar from the anal fissurectomy. There was no indication of any ongoing fissures. Rather, the examination only showed a small, external hemorrhoid. The March 2014 VA examination report indicated there was no change from the December 2013 examination. The February 2022 VA examination confirmed a fissurectomy in 1979 but anal fissures were not noted on physical examination. The examiner noted mild to moderate, internal and external hemorrhoids, accompanied by persistent bleeding. Statements submitted in support of the Veteran's claim from his children, friends and wife were submitted in March 2015 and October 2019. Each person indicated they recalled the Veteran having "bleeding episodes" and having to remain in the bathroom or go lay down due to associated headaches from the blood loss. In his notice of disagreement, the Veteran noted that since service, he has experienced ongoing bouts of severe bleeding. He was seen in the emergency room for blood loss and in November 2012 was given a blood transfusion after his hemoglobin was found to be extremely low. During the February 2021 hearing, the Veteran testified that he suffered chronic bleeding since the fissurectomy and underwent blood transfusions as treatment. He did not experience any issues with sphincter control, as such his current rating under diagnostic code 7332 was inappropriate. Based on the foregoing, a compensable rating for the Veteran's residuals of a fissurectomy is not warranted. His reported symptoms are addressed and compensated in the 20 percent rating assigned above for his hemorrhoids. The evidence of record does not show current fissures or other residuals that would warrant a rating. The Veteran denied any problems with sphincter control or fecal incontinence but indicated that his rectal bleeding was the main issue. However, the medical evidence shows that the Veteran suffered from rectal bleeding that was related to his hemorrhoids. Colonoscopies conducted in December 2016 and again in December 2017 showed several internal and external hemorrhoids, which were found to be the cause of the rectal bleeding. In December 2017, the Veteran continued to report occasional bleeding when straining to use the bathroom, which was directly related to the emergence of hemorrhoids. The Board acknowledges the Veteran's contention that he believes his fissures are the cause of his ongoing bleeding issue and should warrant a higher rating. However, the Veteran is not competent to make such a determination regarding this issue. The issue is medically complex, as it requires knowledge of pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the required medical training or credentials. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA opinions and medical evidence of record. In sum, the Board finds that the medical evidence of record is against a compensable rating for residuals of an anal fissurectomy. REASONS FOR REMAND 1. Entitlement to service connection for a gastrointestinal condition, to include diverticulosis and ulcerative colitis, is remanded. A remand is necessary because the March 2022 VA examiner indicated that the Veteran had not complaints of a gastrointestinal issue in service or at separation. The Board finds the opinion is inadequate as it cannot be based solely on a lack of treatment or complaints in service. Moreover, during the Board hearing, the Veteran testified that he was seen during service for stomach problems and given medication. He had been seeing doctors due to an ongoing gastrointestinal condition since 1973 but did not have a diagnosis. Current treatment records show a diagnosis of diverticulosis and possible ulcerative colitis. Another opinion should be sought on remand to determine if the Veteran's symptoms in service were early manifestations of his current diagnoses. The March 2022 opinion discussed whether the Veteran's gastrointestinal issues were caused by his service-connected disabilities, but failed to include an opinion as to aggravation. Thus, an addendum opinion is necessary to address aggravation. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's diverticulosis and/or ulcerative colitis are at least as likely as not related to the stomach problems he described during service. The examiner is also asked to determine whether the Veteran's diverticulosis and/or ulcerative colitis are aggravated by his service-connected hemorrhoids or residuals of fissurectomy. The examiner should include a detailed rationale for all opinions. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Price, Esq. 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.