BVA9503400 DOCKET NO. 92-18 380 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to an increased rating for hemorrhoids, currently evaluated as 10 percent disabling. 2. Entitlement to an increased rating for chronic abdominal pain, enterocolitis and appendectomy adhesions, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD Joseph P. Gervasio, Jr., Counsel INTRODUCTION The veteran served on active duty from April 1979 to August 1983. This case comes to the Board of Veterans' Appeals (Board) on appeal of a July 1991 rating decision of the Seattle, Washington, Regional Office (RO) of the Department of Veterans Affairs (VA), which denied claims for increased ratings for service-connected hemorrhoids, rated 10 percent, and service-connected abdominal pain, enterocolitis and appendectomy adhesions, rated 10 percent. The case was remanded by the Board in February 1994. It was returned to the Board in December 1994. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that her abdominal disorder and hemorrhoids are more disabling than currently evaluated. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claim for an increased rating for hemorrhoids, and that the evidence supports an increased rating, to 30 percent, for chronic abdominal pain, enterocolitis and appendectomy adhesions. FINDINGS OF FACT 1. The veteran's hemorrhoids are productive of disability which does not exceed that for hemorrhoids which are large or thrombotic, irreducible, with excessive redundant tissue evidencing frequent recurrences. 2. Chronic abdominal pain, enterocolitis, and appendectomy adhesions are productive of aggregate disability which approximates that for moderately severe adhesions of the peritoneum. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for hemorrhoids have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.114, Code 7336 (1993). 2. The criteria for a 30 percent rating for chronic abdominal pain, enterocolitis and appendectomy adhesions have been me. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.114, Code 7301 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS It is initially noted that the veteran's claims on appeal are well grounded; that is, they are not inherently implausible. 38 U.S.C.A. § 5107(a). It is also found that the facts relevant to the issues on appeal have been properly developed to the extent possible, and the statutory obligation of the VA to assist the veteran in the development of his claim has been satisfied. Id. In this regard, it is noted that the case was remanded by the Board in February 1994 so that possible evidence of treatment for service-connected conditions could be obtained. In March 1994 the veteran was notified by the RO that she could send in the treatment records herself, or authorize the VA to obtain the information for her. (Forms for this purpose were provided.) She was told to respond as soon as possible, preferably within 60 days. In September 1994, her representative indicated that the veteran would personally try to obtain the records. However, the records have not been submitted. The duty to assist is not a one- way street. Wood v. Derwinski, 1 Vet.App. 190 (1991). Under the circumstances, there is no further VA duty to assist the veteran with her present claims, and the case has been decided based on the evidence of record. I. Factual Background The veteran served on active duty from April 1979 to August 1983. Service medical records show that in late 1979 she was treated for abdominal pain, and in November 1979 she underwent an exploratory laparotomy and appendectomy. Later service medical records show she was intermittently treated thereafter for abdominal pain, with various causes of the pain being suspected, such as a gastrointestinal disorder. The initial post-service VA examination, in October 1983, led to a diagnosis of status post exploratory surgery for appendicitis with clinical evidence of irritable bowel and constipation. Service connection for an appendectomy scar, rated 10 percent, and enterocolitis, rated noncompensable, was established by rating decision of the RO in January 1985, effective with the veteran's August 1983 release from service. A number of other post-service medical records during the 1980's refer to complaints related to the abdomen and the appendectomy scar, as well as hemorrhoids. Some of the records indicate doctors suspected possible adhesions from the appendectomy or functional bowel disease as being the cause of symptoms, and at times such problems were not found. An April 1989 VA examination led to a diagnostic impression of chronic lower abdominal pain following an appendectomy, with normal diagnostic studies except for hemorrhoids. The examiner suspected that post-appendectomy adhesions were present, and it was noted there were no clinical findings to support a diagnosis of enterocolitis at present. By rating decision in June 1989, the RO described the veteran's service-connected disabilities as chronic abdominal pain, enterocolitis, status-post appendectomy adhesions, rated as 10 percent disabling. Secondary service connection for hemorrhoids was also established and rated as 10 percent disabling. The veteran has submitted some records of non-VA outpatient treatment during 1990. In June 1990 she was seen at a service department facility and received treatment for abdominal pain and tenderness. When seen in November 1990 she had abdominal tenderness and distention, and the assessment was irritable colon syndrome. On that same day she underwent a rectal examination at Group Health Cooperative. Hemorrhoidal tags were noted, and anoscopy and sigmoidoscopy were normal except for a minimal internal hemorrhoid with bleeding. Telephone consultation forms, of Group Health Cooperative, from December 1990 and January "1990" (possibly 1991), refer to complaints of abdominal pain. An examination was performed by the VA in May 1991. The veteran stated that she had had chronic abdominal pain since her surgery in 1979. She said she had significant constipation, with bowel movements occurring once in every 7 to 9 days. She said she had significant hemorrhoids with pain and bleeding as a result. The veteran said she had difficulty with any activity which stretched her abdomen. She said that lifting more than 10 pounds caused significant discomfort. She was currently working as a budget clerk and was a student. It was noted that she was not in acute distress at the time of the examination. Examination of the abdomen disclosed a well-healed, 10 cm vertical scar below the umbilicus. There was marked tenderness to minimal palpation in the mid lower quadrant of the abdomen. There was moderate tenderness to deep palpation throughout the entire abdomen. Bowel sounds were present and there was no rebound tenderness. Rectal examination revealed no external hemorrhoids, but there was marked tenderness to minimal palpation and internal hemorrhoids were palpable. Stool guaiac was negative. The diagnoses were chronic abdominal pain, most likely secondary to adhesions following exploratory surgery for ruptured appendix. The examiner opined that the veteran experienced significant functional limitations due to her chronic abdominal pain. Also diagnosed were internal hemorrhoids with recurrent pain and bleeding, secondary to constipation which was most likely due to adhesions. II. Analysis Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. A. Hemorrhoids A 10 percent evaluation is warranted for large or thrombotic, irreducible, external or internal hemorrhoids with excessive redundant tissue evidencing frequent recurrences. A 20 percent evaluation requires hemorrhoids with persistent bleeding and secondary anemia or with fissures. 38 C.F.R. § 4.114, Code 7336. The most recent outpatient records and VA examination show that the veteran has internal hemorrhoids with episodic bleeding. However, there is no evidence of fissures, persistent bleeding or secondary anemia. The preponderance of the evidence shows the hemorrhoids most clearly approximate the criteria for the existing 10 percent rating. 38 C.F.R. § 4.7. There is no evidence upon which a higher schedular evaluation may be awarded. Neither does the evidence show that the disability is so exceptional or unusual as to render the application of the regular rating standards impractical, and thus an increased rating on an extraschedular basis is not warranted. 38 C.F.R. § 3.321(b)(1). Inasmuch as the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). As such, a rating in excess of 10 percent must be denied. B. Chronic Abdominal Pain, Enterocolitis, and Appendectomy Adhesions While there are multiple aspects of the veteran's service- connected digestive system disability, it is to be rated only under one diagnostic code which best reflects the disability picture. 38 C.F.R. §§ 4.14, 4.113, 4.114. A 10 percent evaluation is warranted for moderate adhesions of the peritoneum, with pulling pain on attempting work or with occasional episodes of colic pain, nausea, constipation (perhaps alternating with diarrhea) or abdominal distention. A 30 percent evaluation requires moderately severe adhesions, with partial obstruction manifested by delayed motility of barium meal and less frequent and less prolonged episodes of pain than are present with severe adhesions. A 50 percent evaluation requires severe adhesions with definite partial obstruction shown by X-ray study, frequent and prolonged episodes of severe colic, distention, nausea or vomiting following severe peritonitis, a ruptured appendix, a perforated ulcer, or an operation with drainage. 38 C.F.R. § 4.144, Code 7301. Chronic enterocolitis is rated as irritable colon syndrome. 38 C.F.R. § 4.114, Code 7326. A 10 percent evaluation is warranted for moderate irritable colon syndrome manifested by frequent episodes of bowel disturbance with abdominal distress. A 30 percent evaluation requires severe irritable colon syndrome manifested by diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114, Code 7319. The evidence shows the predominant aspect of the service- connected condition (abdominal pain, enterocolitis, and appendectomy adhesions) involves the pain from adhesions, and the disability is most appropriately rated under Code 7301. The outpatient records from the year preceding the 1991 VA examination show multiple treatment episodes primarily involving abdominal pain and tenderness. At the 1991 VA examination the veteran gave a history of chronic abdominal pain and significant constipation. Objective findings included moderate to marked tenderness on palpation of different parts of the abdomen, and the diagnosis was chronic abdominal pain likely secondary to postoperative adhesions. The doctor felt there was significant functional impairment from the condition. The medical evidence does not show each and every one of the criteria for moderately severe (30 percent) adhesions of the peritoneum as listed in Code 7301, but in the judgment of the Board there are findings sufficiently characteristic of this level of disability. 38 C.F.R. § 4.21. This is especially so when considering all elements of the multifaceted digestive disability which support elevation of the next higher level (38 C.F.R. § 4.114), and in view of the benefit-of-the-doubt doctrine (38 U.S.C.A. § 5107(b)), and evidence tending to show the disability more nearly approximates the higher 30 percent rating criteria than the lower 10 percent criteria (38 C.F.R. § 4.7). For these reasons, the Board holds that an increased rating, to 30 percent, is warranted for this disability. ORDER An increased rating for hemorrhoids is denied. An increased rating, to 30 percent, for chronic abdominal pain, enterocolitis and appendectomy adhesions is granted. L. W. TOBIN Member, Board of Veterans' Appeals (CONTINUED ON NEXT PAGE) The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.