BVA9503781 DOCKET NO. 92-09 588 ) DATE ) RECONSIDERATION ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUE Entitlement to service connection for peptic ulcer disease. REPRESENTATION Appellant represented by: American Red Cross WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Jeffrey A. Pisaro, Counsel INTRODUCTION The veteran had active service from November 1968 to December 1971. By decision of the Board of Veterans' Appeals (Board) in April 1984, service connection for peptic ulcer disease was denied. This appeal arises from a September 1991 rating decision of the Milwaukee, Wisconsin, Regional Office (RO). The Board remanded the case to the RO in November 1992 for additional development of the evidence. It was also determined that new and material evidence had been submitted, and the veteran's claim was reopened; accordingly, the instant claim will be adjudicated on a de novo basis. The Board entered a decision in this case in April 1994, denying the veteran's claim for entitlement to service connection for peptic ulcer disease. Subsequently, a Motion for Reconsideration of that decision was filed with the Board in April 1994. Reconsideration of the April 1994 decision was ordered in July 1994 by the authority granted to the Chairman in 38 U.S.C.A. § 7103 (West 1991), and the case is now before an expanded Reconsideration panel of the Board. This decision by the Reconsideration Section replaces the Board's April 1994 decision and is the final decision of the Board. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends that the RO erred by failing to grant service connection for peptic ulcer disease which was either incurred during service or is proximately due to or the result of service connected post traumatic stress disorder (PTSD). It is contended that development is incomplete as the veteran was not afforded a Department of Veterans Affairs (VA) examination pursuant to the November 1992 remand, and it is asserted that a medical text cited by the veteran was not considered. It is further requested that the case be referred for a independent medical opinion to resolve conflicting opinions regarding the etiology of the peptic ulcer disease. 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 files. 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 veteran's claim. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's claim has been obtained by the RO. 2. Peptic ulcer disease was first manifest many years following separation from service. 3. Peptic ulcer disease is not etiologically related to PTSD. 4. The issue concerning service connection for peptic ulcer disease does not involve medical complexity or controversy requiring an advisory opinion from an independent medical expert. CONCLUSIONS OF LAW 1. Peptic ulcer disease was not incurred in or aggravated by service, it may not be presumed to have been so incurred, nor is it due to or the result of a service connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 1991); 38 C.F.R. §§ 3.307, 3.309, 3.310 (1993) 2. An advisory opinion from an independent medical expert is not warranted. 38 U.S.C.A. §§ 5107, 7109 (West 1991); 38 C.F.R. § 20.901(d) (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran's claim is well grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, the Board finds that he has presented a claim which is plausible. This test having been met, the Board must examine the record and determine whether there is any further obligation to assist the veteran in the development of that claim. The November 1992 remand contained two evidentiary requests, to allow the veteran to present additional evidence and to afford the veteran a VA gastrointestinal examination. Regarding the former, the veteran reported through his representative in writing in January 1993 that all medical evidence was of record. The VA examination report was to provide an opinion as to the etiology and date of onset of the veteran's peptic ulcer disease. Although the veteran did not receive a current examination, the Chief of the Milwaukee VA G.I. section provided a written opinion regarding the etiology of the veteran's peptic ulcer disease based on a review of the entire medical record. As the current degree of disability due to peptic ulcer disease has no plausible relevance to the etiology and date of onset of that disorder many years before, the failure to provide an examination is harmless error. The Board finds that the duty to assist has been completed. Service connection will be granted for peptic ulcer disease if the evidence establishes that such a disability was incurred in or aggravated by service, 38 U.S.C.A. § 1110; if the evidence demonstrates that peptic ulcer disease was manifest to a compensable degree within the initial post service year, 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309; or if the evidence establishes that peptic ulcer disease is proximately due to or the result of a service connected disability. 38 C.F.R. § 3.310. In April 1969, the veteran was treated at Milwaukee County Emergency for a two week history of "cramping" epigastric and right upper quadrant pain which radiated through to the back. Discomfort was relieved with the administration of Maalox. The diagnosis was abdominal pain of uncertain etiology; possible gastric hyperacidity. In October 1969, a one week history of epigastric area pain was reported. The veteran also reported some vomiting and atypical epigastric pain for two to three weeks with no apparent relationship to food. On examination, there was no epigastric hernia present. In December, increased epigastric pain was reported while eating. On the December 1971 separation examination, the abdomen and viscera were clinically evaluated as normal. Employment medical records from 1972 and 1973 include a September 1972 notation of stomach flu, nauseated. The abdomen was slightly tender throughout. In March 1973, it was reported that the veteran had been vomiting since the previous Friday and unable to eat. The veteran was treated in June 1973 at Milwaukee County Emergency for complaints to include abdominal pain of four days' duration. No history of an ulcer was reported. Diagnoses include non-emergency gastritis. A March 1976 outpatient treatment notation from St. Joseph's Hospital reveals complaints of cramping in the stomach and back. A history of gastritis in the past was reported; the diagnosis was gastritis. A December 1977 treatment notation from Milwaukee County Medical Complex shows that the veteran reported having a "virus" for seven years that he had caught in service that would come and go every two to three months. Several work ups and hospital admissions reportedly had been negative. The veteran reported having pain in the epigastric area and cramping which occasionally radiated straight back. No nausea or vomiting was reported. On examination, there was slight tenderness in the epigastric area. The diagnosis was abdominal pain of questionable etiology. A July 1978 record from Milwaukee County Medical Complex indicates multiple episodes of multiple complaints. Epigastric pain and vomiting since the previous evening were reported. The diagnosis was gastritis. A December 1978 notation from Milwaukee County Medical indicates a history of pancreatitis. The veteran reported that pains had increased over the last week. The diagnosis was abdominal pains, probably mild pancreatitis. The veteran was treated for pancreatitis at a VA medical facility between July and December 1978. The veteran was hospitalized at Foundation Hospital of Milwaukee from March to April 1979 with a nine year history of abdominal pain, mostly in the epigastrium. An upper G.I. series revealed a penetrating duodenal and prepyloric ulcer. A gastroscopy revealed a small antral ulcer and duodenal ulcers at the apex of the bulb. A vagotomy and antrectomy with Bilroth II were performed. The diagnosis was penetrating peptic ulcer disease. Multiple statements were submitted in February 1983 from family members and a long time friend which, in the aggregate, indicate that although the veteran was healthy upon entering the military, he had a stomach disorder when discharged with symptoms including pain, vomiting, and cramping. The veteran testified at an August 1992 personal hearing which was conducted at the Board. He stated that his stomach problems began during service in 1969 and had continued on through the post service years. When 1/3 of his stomach was removed in 1979, the veteran reported having been told that it would have taken a long time for his condition to reach that point. (T-14). The veteran stated that his psychiatrist, Sheldon Chicks, M.D., had indicated that there was a relationship between his service connected PTSD and peptic ulcer disease. A photocopy of an excerpt from Cecil Textbook of Medicine was submitted at the hearing. Testimony previously offered at a February 1992 personal hearing at the RO was essentially similar to the testimony given in August 1992. The Chief of the Gastrointestinal Section of the Milwaukee, Wisconsin VA medical center authored the following memorandum in April 1993: 1. We were asked by the Compensation and Pension Unit to conduct a gastrointestinal examination to provide an opinion as to the etiology and date of onset of peptic ulcer disease. 2. In our initial review of the Board of Veteran's Appeal dated 11/1992, the issue of entitlement for service connection for peptic ulcer disease was examined. We reviewed the testimony by [the veteran] in this appeal and noted that in his description of his disorder, he received diagnosis, treatment, and surgery for what was diagnosed as a stomach condition at Milwaukee County Medical Center. We therefore requested that the Compensation and Pension Board obtain these outside records from Milwaukee County Medical Center. The following opinion is based upon review of those records from Milwaukee County Medical Center. 3. Providing an opinion as to the etiology of peptic ulcer disease is difficult. In most instances, the cause of peptic ulcer disease is yet unknown. There are a small number of patients who have peptic ulcer disease because they have tumors called gastrinomas which secrete a hormone causing the stomach to produce excessive amounts of acid. There is no present evidence that [the veteran] has a gastrinoma as a cause of peptic ulcer disease. In addition, there are rare genetic syndromes associated with peptic ulcer disease. These include: multiple endocrine adenomatosis, Type I, systemic mastocytosis, ulcer-tremor- nystagmus syndrome, amyloidosis, Type 4, stiff-skin syndrome, pachydermoperiostosis, multiple lentigines-ulcer syndrome, and Leukonychia-gallstone-ulcer syndrome. Review of the available records from Milwaukee County Medical Center show no evidence that the patient has any of these rare genetic syndromes that are associated with peptic ulcer disease. 4. There is presently no direct evidence in the literature which is available to us that proves that post-traumatic stress disorder causes peptic ulcer disease. I have reviewed this topic with Dr. Amnon Sonnenberg of our Division of Gastroenterology who has written more than 100 manuscripts on peptic ulcer disease. Briefly, experts in the field of peptic ulcer disease believe that peptic ulcer disease itself can be exacerbated or worsened during periods of stress. However, examining patients who have very stressful jobs, such as air traffic controllers, has revealed that these people do not have an increased incidence of duodenal ulcer. Therefore, there is no direct evidence that stress itself can cause a peptic ulcer. This subject is reviewed in detail by Dr. Andrew H. Soll in Gastrointestinal Disease, (Sleisenger and Fordtran, editors), 4th edition; page 823, 1989. 5. We have also reviewed the question of date of onset of peptic ulcer disease. To summarize, review of [the veteran's] records shows: 1) His initial visit to Milwaukee County Emergency Room was at age 19 on 4/26/69. He was in active military service at the time, and was home on leave. He was seen at that time for a 2 week history of cramping, epigastric and right upper quadrant pain radiating through to the back which was initially relieved by antacids, but had not been relieved by antacids on this day following a meal which contained fried ham. The patient was given 2 ounces of Maalox and it was noted that his discomfort was completely relieved. He was signed out as abdominal pain of uncertain etiology, possible gastric upset and it was recommended that he see his personal physician if he had persistent problems. 2) His next visit to the Milwaukee County Medical Center on 9/24/72 (which was after his release from active service) showed that he was seen for nausea with a physical exam revealing "abdomen slightly tender throughout". Diagnosis of "stomach flu" was made at that time. He was seen again for an episode of emesis on 3/3/73. 3) The next Milwaukee County Emergency Room visit was on 6/28/73 for complaint of abdominal pain. It stated that he denied the occurence of melena or hematemesis but it did show that he was drinking alcohol at that time. It also stated that he had no history of an ulcer. His hematocrit at that time was 51.5 (which is within the range of normal) and his abdominal exam was said to be normal. 4) [the veteran] was then again seen at Milwaukee County Medical Complex on 7/1/78 (which then was 6 years and 8 months following his release from active service). He was seen for a 1 day history of epigastric pain associated with emesis. A diagnosis of gastritis was made at that time and he was treated with Maalox. 5) The next visit to the Milwaukee County Medical Complex occurred on 12/26/78 and it showed at that time he had been treated for pancreatitis during 1978. Diagnosis of abdominal pain due to pancreatitis was made at that time. He was treated with Demerol. 6) The next medical report is dated 3/13/79. This report revealed that on 2/25/79 he had alcohol intake, but none since then. He was seen for mid-epigastric pain. This pain apparently had been present for a period of 3 weeks. A recent upper GI x-ray was said to be "negative". He had no evidence of blood in the stool at that time. No diagnosis was made. 7) Patient was seen at the Milwaukee County Medical Complex on 3/14/79. It was noted that he had a history of recurrent pancreatitis and recently began to have abdominal pain with the use of alcohol. His abdominal exam was not revealing at that time. A diagnosis of pancreatitis was made. 8) Patient was then seen at the Milwaukee County Medical Complex on 3/17/79. Records stated that he was seen twice that week at St. Michael's Hospital with elevation of amylase. Diagnosis of pancreatitis was again made. 9) The next record dated 3/20/79 from a clinic on W. Chambers Street showed that he had a 3 week history of abdominal pain associated with vomiting and diarrhea. At that time, he had a normal hemoglobin and a mild elevation of amylase at 80. The diagnosis at that time was abdominal pain ? mild pancreatitis versus gastritis. 10) As an apparent follow-up to these multiple emergency room visits, on 3/30/79 patient had an esophagogastroduodenoscopy performed. This examination showed a normal esophagus. The patient had diffuse superficial gastritis with a small benign appearing gastric ulcer adjacent to the pylorus. In addition, in the apex of the duodenal bulb, there were 2 ulcerations noted with surrounding erythema and edematous mucosa. 11) In conclusion of his records, he had a surgical pre-operative note dated 4/1/79 which was 2 days following his esophagogastroduodenoscopy. This note is difficult to interpret because it now stated that [the veteran] had had a 9 year history of abdominal pain in the epigastrium. It does not state how long his most recent epigastric pain radiating to the back had been present. It did again address his alcohol history which was said to be a 6 pack of beer a day. Based upon his symptoms and history, on 4/2/79 the patient underwent a truncal vagotomy and antrectomy with formation of a Billroth II reanastomosis. Pathologic review of the antrum revealed some flattening in the gastric mucosa and the presence of lymphoid follicles in the mucosa, which are non- specific findings. 6. In summary, esophagogastroduodenoscopy in 3/30/79 revealed the presence of a pre- pyloric ulcer and 2 duodenal ulcers. The length of time that these ulcers had been present is difficult to determine. The patient had multiple admissions in the late 1970's for the diagnosis of pancreatitis. The available notes had indicated that his previous abdominal pain appeared to be related to heavy alcohol use. A visit on 3/13/79 specifically stated that the patient had had an upper GI which was "negative". The best dating of the onset of duodenal ulcer disease for which the patient required an operation would seem to indicate that it had began approximately on 2/25/79. In summary of the etiology of this disorder, again we have no direct evidence that post-traumatic stress disorder causes duodenal ulcer disease. Stress is not thought to be a cause of duodenal ulcer disease but may exacerbate ongoing duodenal ulcer disease. There is little evidence that alcohol use is a risk factor for duodenal ulcer disease, unless the patient has developed alcoholic cirrhosis, for which we have no present evidence. I believe that these are the best opinions that we can provide as to the etiology and date of onset of duodenal ulcer disease in [the veteran]. In a July 1993 statement from Sheldon Chicks, M.D., he indicated that the veteran had been continuously under his psychiatric care since January 1985. In a September 1994 statement, Dr. Chicks stated that he could be of no medical service in regards to the veteran's peptic ulcer claim; however, Dr. Chicks indicated that peptic ulcer disease had started during service as gastritis is commonly known to be a forerunner of "peptic ulcer", --that is, that the natural course of an enduring gastritis is likely to be progression to frank peptic ulcer. The medical record demonstrates that peptic ulcer disease was first diagnosed in March 1979, more than seven years following separation from service. That fact is uncontested. As peptic ulcer disease was first diagnosed many years following separation from service, service connection on a direct or presumptive (within one year) basis is not appropriate. The crux of the veteran's case is based on two theories: 1) that the medical record from 1969 to 1979 evidences the existence of peptic ulcer disease although that disability was not yet diagnosed, and 2) that peptic ulcer disease is etiologically related to service connected PTSD. Neither contention withstands evidentiary and medical scrutiny. As to the first contention, the record shows treatment for epigastric symptoms beginning in 1969 to include cramping, pain, and vomiting. A diagnosis of gastritis was first made in June 1973, more than one year after separation from service. In 1978, many years after separation, pancreatitis was diagnosed. The veteran has submitted an excerpt from a medical text which indicates that peptic ulcer disease patients suffer symptoms which range from five to ten years in duration in 30 percent of the cases. The Chief of the Milwaukee VA G.I. Section reviewed the veteran's medical history and medical literature, and concluded that peptic ulcer disease, though difficult to date as to onset, most likely was first manifest in February 1979. Dr. Chicks, a psychiatrist who has not reviewed the veteran's entire medical history, stated in September 1994 that as gastritis, which he reports was treated in service, is the forerunner of peptic ulcer, service connection should be granted. That opinion is contrary to the evidence as gastritis was first diagnosed in June 1973 more than one year after separation; thus, Dr. Chick's theory is factually incorrect. Furthermore, the veteran's testimony and multiple statements from family and friends submitted in February 1983, corroborate that the veteran suffered from ongoing stomach symptoms following service. They do not constitute a medical opinion as to the date of onset of peptic ulcer disease. VA law is clear that laymen are not competent to offer such a medical opinion. Espiritu v. Derwinski, 2 Vet.App. 492 (1992); and Moray v. Brown, 5 Vet.App. 211 (1993). As to the second contention, the VA G.I. Section Chief's opinion is again highly persuasive. Following a review of medical literature and a discussion of the veteran's case with a well published specialist in this area of medicine, it was opined that there was no plausible nexus between PTSD and the development of peptic ulcer disease. There is nothing in the record to rebut that opinion, to include the interpretation of the medical literature on the subject. In fact, Dr. Chicks, contrary to the veteran's contention in his personal hearing, has not opined that the veteran's peptic ulcer disease was etiologically related to PTSD. In view of the above, as the claim lacks a basis for medical controversy, the request for an independent medical opinion is without merit. The Board finds that the preponderance of evidence is against the claim for entitlement to service connection for peptic ulcer disease. ORDER Entitlement to service connection for peptic ulcer disease is denied. HOLLY MOEHLMANN I. S. SHERMAN Member, Board of Veterans' Appeals Member, Board of Veterans' Appeals C. W. SYMANSKI Member, Board of Veterans' Appeals MIKE D. LYON URSULA R. POWELL Member, Board of Veterans' Appeals Member, Board of Veterans' Appeals LAWRENCE M. SULLIVAN Member, Board of Veterans' Appeals (Continued Next Page) 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.