Internet Medical Information

[gousto64]

Citation Nr: 0902694

Decision Date: 01/27/09 Archive Date: 02/09/09

DOCKET NO. 05-01 859 ) DATE

)

)

On appeal from the

Department of Veterans Affairs Regional Office in St. Louis,

Missouri

THE ISSUE

Entitlement to service connection for gastroesophageal reflux

disease (GERD), to include as secondary to the service-

connected conditions of chronic obstructive pulmonary disease

("COPD") and cervical disc protrusion at C3 and C4 ("back

disability").

REPRESENTATION

Appellant represented by: The American Legion

WITNESS AT HEARING ON APPEAL

Appellant

ATTORNEY FOR THE BOARD

S. Finn, Associate Counsel

INTRODUCTION

The veteran served on active duty from July 1977 to July

1997.

This matter comes before the Board of Veterans' Appeals

(Board) on appeal from an August 2003 rating decision of the

Department of Veterans Affairs (VA) Regional Office (RO) St.

Louis, Missouri. The veteran perfected a timely appeal of

the rating action to the Board.

In March 2008, the veteran testified at a Travel Board

hearing before the undersigned Veterans Law Judge. A copy of

this hearing transcript has been associated with the claims

file.

The issue of entitlement to an increased rating in excess of

10 percent for service-connected postoperative cervical

spine, to include radiculopathy of the shoulders has been

withdrawn and is no longer on appeal. (See October 2007

written statement).

FINDING OF FACT

The competent medical evidence of record shows that the

medications the veteran took for his service-connected back

disability and COPD aggravated his GERD.

CONCLUSION OF LAW

The veteran's GERD is proximately due to his service-

connected back disability and COPD. 38 U.S.C.A. §§ 1110,

1131, 5103, 5103A (West 2002); 38 C.F.R §§ 3.159, 3.303,

3.310(a) (2008).

REASONS AND BASES FOR FINDING AND CONCLUSION

I. Duty to Notify and Assist

As provided for by the Veterans Claims Assistance Act of 2000

(VCAA), VA has a duty to notify and assist claimants in

substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100,

5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a),

3.159 and 3.326(a). In this case, the Board is granting in

full the benefits sought on appeal.

Any defect, if one exists, with respect to either the duty to

notify or the duty to assist must be considered harmless and

will not be discussed.

II. Service Connection for GERD

Service connection may be granted for a disability resulting

from disease or injury incurred in or aggravated by service.

38 U.S.C.A. §§ 1110, 1131; 38 C.F.R.

§ 3.303(a). 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. If chronicity in service

is not established, a showing of continuity of symptoms after

discharge is required to support the claim. 38 C.F.R. §

3.303(. Service connection may also be granted for any

disease diagnosed after discharge when all of the evidence

establishes that the disease was incurred in service. 38

C.F.R. § 3.303(d).

Service connection may also be granted for certain chronic

diseases when it is manifested to a compensable degree within

one year of separation from service. 38 U.S.C.A. §§ 1101,

1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309.

Service connection may also be established on a secondary

basis for a disability which is proximately due to or the

result of a service-connected disease or injury; or, for 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

progression of the non-service-connected disease. 38 C.F.R.

§ 3.310 (2005); Allen v. Brown, 7 Vet. App. 439 (1995) (en

banc).

In order to establish service connection for the claimed

disorder, there must be (1) a current disability; (2) medical

or, in certain circumstances, lay evidence of the in-service

incurrence or aggravation of a disease or injury; and (3)

medical evidence of a nexus between the claimed in-service

disease or injury and the current disability. See Hickson v.

West, 12 Vet. App. 247, 253 (1999).

Here, the veteran claims that his GERD is secondary to

medications taken for his service-connected COPD and C3-C4

disc protrusion with neural foraminal encroachment. His

basic contention is that his claimed disorder was caused by

the use of Prednisone. In an October 1997 rating decision,

service connection was awarded for COPD and a June 1996

Supplemental Statement of the Case granted service connection

for the back disability.

Medical treatment records reflect that the veteran used

Prednisone from 1996 to November 1999. (See Treatment record

dated from May 1996 to September 1999).

The veteran was also noted to be using Ranitidine during an

August 2000 VA respiratory diseases examination. Recent VA

medical records indicate treatment and medication for GERD.

A January 2002 VA record reflects that GERD was among the

diseases in the veteran's medical history. The section of

the veteran's December 2004 VA spine examination report

addressing his past medical history indicates that he had to

take Omeprazole "due to his chronic gastroesophageal; reflux

problems with long-term therapy on nonsteroidals and

[P]rednisone therapy."

In April 2005, R.H., M.D., noted that he had treated the

veteran since August 2003. The veteran was noted to have a

history of peptic ulcer disease and gastritis and was

currently being treated with 20 mg of Omeprazole daily. In

regard to the risk factors for developing this disease

process, the veteran's prior history of Prednisone use for

many years was "at least partially a contributing factor."

The veteran underwent a VA esophagus and hiatal hernia

examination in June 2005. In the report of this examination,

the examiner did not specify which records had been reviewed

in conjunction with the examination; she did, however, note

prior records, including a January 2003 MRI and an undated

EMG report. During the examination, the veteran noted that

he had not been on Prednisone since his discharge from

service. The examiner rendered a diagnosis of erosive

esophagitis secondary to reflux. She stressed that there was

no evidence to suggest that this diagnosis "is secondary"

to his steroid use, as he had not been on steroids since

1997. The veteran was noted to have a multitude of factors

resulting in erosive esophagitis, including alcohol and

smoking and "his narcotic as well as nonsteroidal use for

pain control as well as his reflux." The VA examiner,

however, did not address whether the veteran's steroid use

aggravated his GERD.

The Board also observes that, in February 2008, T.N., D.O.,

noted that Prednisone was well-documented to markedly

sensitize and worsen GERD, gastritis, and duodenitis, all of

which the veteran was noted to have. He also stated that the

veteran had a current diagnosis of GERD and that it was at

least likely as not that the Prednisone he took for his lung

condition caused his current condition of GERD.

The Board requested a VHA opinion in October 2008 for

clarification of the etiology of the veteran's GERD. The VA

examiner noted the veteran's history and medication use of

oral, inhaled, and injected steroids, as well as anti-

inflammatory agents for his COPD and disc problems. He

stated that two of the medications have been associated with

the development of esophagitis, gastritis, and peptic ulcer

disease. He noted that the veteran had a prior endoscopy

that documented the presence of gastritis and esophagitis;

and, that this usually occurs temporally with recent or

ongoing use of NSAIDs or oral steroids. With regard to the

complications, the examiner stated that:

t is felt that steroids and NSAIDs do have a

causal relationship and this association has been

well-documented in many medical papers. However,

with respect to chronic reflux, there is no data to

suggest that steroids or NSAIDs cause chronic

reflux or GERD.

He further stated that:

[W]hile steroids and NSAIDs may not have caused

GERD, certainly these medications can exacerbate

reflux symptoms. Furthermore, these medications

can cause espophagitis, gastritis, and ulcers,

complications [that] the veteran has been found to

have on endoscopy.

He concluded that a number of factors can worsen or aggravate

reflux including steroids as well as smoking; and, that it

was as least likely as not that steroids and/or NSAIDs

aggravated his GERD.

The veteran also submitted numerous studies linking gastritis

to steroid use. (See Gastritis Causes, at

http://www.emedicinehealth.com (last visited Feb. 23, 2008);

Major Side Effects of Glucocorticoids, at

http://uptodateonline.com (last visited Apr. 7, 2005);

Prednisone The Drug We Love to Hate, at http://ibdcrohns.

about.com (last visited at Feb. 2008 ); et. al. The Board

notes that medical treatise evidence can, in some

circumstances, constitute competent medical evidence. See

Wallin v. West, 11 Vet. App. 509, 514 (1998); see also 38

C.F.R. § 3.159(a)(1) [competent medical evidence may include

statements contained in authoritative writings such as

medical and scientific articles and research reports and

analyses]. However, the Court has held that medical evidence

that is speculative, general or inconclusive in nature cannot

support a claim. See Obert v. Brown, 5 Vet. App. 30, 33

(1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463

(1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996).

In reviewing the above evidence, the Board notes that the

evidence indicates a multifactorial etiology of GERD. In any

event, the evidence clearly shows that the medication used

for the veteran's COPD and back disability at least

aggravated the veteran's GERD. What is less clear is the

extent to which the medication played a causal role with

GERD. Regardless, the Board is satisfied that the inquiries

necessitated by 38 C.F.R. § 3.303(B) as to any "baseline"

disability have thus been fully addressed, and any doubt in

this instance should be resolved in the veteran's favor. See

Mittleider v. West, 11 Vet. App. 181, 182 (1998) (when it is

not possible to separate the effects of a nonservice-

connected condition from those of a service-connected

condition, reasonable doubt should be resolved in the

claimant's favor with regard to the question of whether

certain signs and symptoms can be attributed to the service-

connected condition).

While both VA examiners concluded that the medications taken

for the service-connected low back disability and COPD did

not cause the veteran's GERD, at least one VA examiner

concluded that the medications taken for the service-

connected back disability and COPD aggravated the GERD. When

the aggravation of a non-service-connected disorder is

proximately due to or the result of a service-connected

disorder, service connection is warranted. Allen v. Brown, 7

Vet. App. 439, 448 (1995). The Board finds the statement of

the VA examiner, combined with the private positive nexus

opinions submitted by the veteran, to be sufficient medical

evidence of a link between the medications and the veteran's

claimed aggravation of his GERD. Overall, the preponderance

of the evidence is in favor of the veteran's claim, as such

service connection is warranted on a secondary basis.

ORDER

Entitlement to service connection for GERD, to include as

secondary to the service-connected conditions of COPD and

cervical disc back disability, is granted.

[carlie]

Just to be aware - that this decision did not grant the claim

due only to Internet Information --

there were doctors opinions as to the disability, the internet info,

and support of full medical rationale.

carlie

[john999]

The VA repeats constantly that it judges each claim on its individual merits. Also, BVA decisions don't set precedents. You need the medical opinion in your particular case.

[gousto64]

Just to be aware - that this decision did not grant the claim

due only to Internet Information --

there were doctors opinions as to the disability, the internet info,

and support of full medical rationale.

carlie

I'LL TRY AGAIN