BVA9508449 DOCKET NO. 90-44 720 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for a gastrointestinal disorder, diagnosed as irritable bowel syndrome and hiatal hernia. 2. Entitlement to an increased (compensable) evaluation for laparotomy scar, post operative incision of abdominal adhesions. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Hudson, Associate Counsel INTRODUCTION The veteran had verified active service from June 1969 To June 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a regional office (RO) rating decision of February 1990 which, in pertinent part, granted service connection for a laparotomy scar, and assigned an noncompensable rating, and denied service connection for gastroenteritis. In May 1991, the case was remanded for development of the issue of an increased evaluation for laparotomy scar. In August 1991, service connection for hiatal hernia, as well as gastroenteritis, was denied. In June 1992, the case was again remanded; at that time, only the increased rating issue had been developed for appellate consideration. However, the veteran's correspondence addressed the issue of service connection for a gastrointestinal issue as well, and the case was remanded for development of this issue in August 1993. Following the completion of the requested development, including appellate development of a rating action denying service connection for a gastrointestinal disorder in December 1993, the case has been returned to the Board for appellate consideration of both issues. CONTENTIONS OF APPELLANT ON APPEAL The veteran essentially contends that he suffers from a gastrointestinal disorder as a result of the laparotomy he underwent in service. He asserts that he has gastrointestinal manifestations including nausea, indigestion, regurgitation, and alternating diarrhea and constipation, which all began following the inservice laparotomy. He believes that, regardless of terminology, he has some sort of chronic stomach disorder resulting from this surgery, and for which there is documentation beginning in 1983. 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 evidence supports a grant of service connection for irritable bowel syndrome; is evenly balanced regarding the claim for service connection for a hiatal hernia, and is against the claim for a compensable evaluation for a laparotomy scar. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appellant's appeal has been obtained by the originating agency. 2. Although not diagnosed until after service, complaints attributable to irritable bowel syndrome and hiatal hernia were present in service. 3. A laparotomy scar is well-healed, with no residual functional impairment. 4. Neither an exceptional nor unusual disability picture has been presented so as to render impractical the application of the regular schedular standards. CONCLUSIONS OF LAW 1. Irritable bowel syndrome and hiatal hernia were incurred in active peacetime service. 38 U.S.C.A. §§ 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1994). 2. The criteria for a compensable evaluation for laparotomy scar have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.10, Part 4, Code 7805-7301 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, we find that the appellant's claim is well-grounded. 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet.App. 78 (1991). In this regard, he has submitted evidence of a plausible claim regarding both issues. The relevant facts have been properly developed, and, accordingly, the statutory obligation of the Department of Veterans Affairs (VA) to assist in the development of the appellant's claim has been satisfied. Id. Factual Background Service medical records reveal the veteran was evaluated in January 1973 for complaints of abdominal pain. By the time of a surgical consultation, the symptoms had diminished, and the impression was probable gastroenteritis. In April 1979, he was hospitalized for evaluation of abdominal pain. Pertinent history included surgery at the age of 5 for a ruptured appendix. An exploratory laparotomy revealed multiple adhesions in the right lower quadrant which were "taken down." He did well postoperatively. The final diagnosis was multiple adhesions, right lower quadrant, with small bowel obstruction. In May 1979, he was noted to be doing well with his only complaints being that things tasted different and that he was somewhat tired. The wound was well-healed. A barium enema in December 1987, to evaluate complaints of decreased caliber of stools, disclosed no significant abnormality. In connection with a retirement examination, the veteran was evaluated in April 1989 for complaints of increased gas and sour breath since the surgery. He did not have diarrhea, but sometimes had constipation, and complained of symptoms of reflux. The impression was that the symptoms were not related to the previous surgery. A gallbladder ultrasound was normal, as was an upper gastrointestinal series. It was specifically noted that the esophagus was normal without hiatal hernia or reflux. Subsequent to service, the veteran underwent a VA examination in October 1989, where he complained of abdominal gas and discomfort, with belching and regurgitation, especially after ingesting dairy products. Physical examination revealed positive bowel sounds and surgical scars in the mid-line and right lower quadrant. The pertinent diagnosis was probable reflux esophagitis, by history. At a hearing before the Board in April 1991, the veteran testified regarding his symptoms, chiefly of alternating constipation and diarrhea, and regurgitation after eating, particularly with certain foods such as those containing dairy products. An outpatient treatment note dated in June 1991 shows complaints of alternating diarrhea and constipation. The assessment was irritable bowel syndrome. In connection with another VA examination, an upper gastrointestinal series was conducted in August 1991, which revealed a hiatal hernia. A barium enema in October 1991 disclosed residual feces in the colon, a normal contrast study, and satisfactory evacuation. The impression was no radiological abnormalities noted pertaining to abdominal surgery. According to an operative report from Community Medical Center dated in August 1992, the veteran underwent a colonoscopy and esophagogastroduodenoscopy. In addition, a colonic polypectomy was performed. The impression was that the veteran's intermittent diarrhea and constipation were possibly due to problems with a spasmal intestine. The polyp was of a benign type which was not believed to cause any problems. The upper endoscopy revealed some evidence of gastritis and hiatal hernia which could account for his symptoms of indigestion and regurgitation. The postoperative diagnoses were hiatal hernia, gastritis, ascending colonic polyp, and possible irritable bowel syndrome. In September 1993, the veteran underwent a VA examination, which disclosed quite active bowel sounds. There was a greater than 20 centimeters midline scar, secondary to laparotomy. An esophogram showed no abnormality. No hiatal hernia or reflux was seen. It was noted that although the veteran related his gastrointestinal symptomatology to the laparotomy, it appeared etiologically that he had irritable bowel syndrome unrelated to the laparotomy. Nevertheless, the examiner pointed out that the symptomatology had been present since service, and concluded that irritable bowel syndrome had probably been present when the veteran was discharged from service. His diagnosis, based on a review of the record, was irritable bowel syndrome, lactose intolerance, and by previous colonoscopy and upper endoscopy, hiatal hernia and history of gastritis. Service connection for a gastrointestinal disorder Service connection may be established for chronic disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1994). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310 (1994). The veteran is service connected for post-operative residuals of a laparotomy, and he contends that his various gastrointestinal manifestations all ensue from that procedure. No medical connection between the laparotomy, which was performed for lysis of adhesions and to relieve a small bowel obstruction, and current gastrointestinal complaints has been shown. However, although radiographic studies in service were normal, irritable bowel syndrome would not be ruled out by such studies. Moreover, as pointed out by the examining physician in September 1993, the veteran began experiencing symptoms referable to irritable bowel syndrome while he was in service. Consequently, because the veteran began experiencing symptoms consistent with irritable bowel syndrome prior to his discharge from service, and currently has a diagnosis of irritable bowel syndrome, we are of the opinion that, with the resolution of all reasonable doubt in the veteran's favor, the evidence supports a grant of service connection for irritable bowel syndrome. Regarding the upper gastrointestinal manifestations, the evidence is less certain. The evidence in the veteran's favor consists of complaints of reflux in service. In addition, an upper gastrointestinal series in August 1991 disclosed a hiatal hernia, as did an endoscopic examination in August 1992. It was felt that this, as well as evidence of gastritis, could account for symptoms of indigestion and regurgitation. The evidence against the veteran consists of an upper gastrointestinal series in service which did not reveal a hiatal hernia or reflux at that time. In addition, an esophogram in September 1993 did not disclose hiatal hernia or reflux. Thus, two tests have disclosed a hiatal hernia and two tests have not. Moreover, the test in service did not. Nevertheless, the endoscopic examination, which is a more sensitive test than the others conducted, did confirm the presence of a hiatal hernia, which "could" account for his symptoms. Consequently, the evidence is evenly balanced. In such cases, the veteran prevails; accordingly, service connection for hiatal hernia is warranted. 38 U.S.C.A. § 5107(b) (West 1991); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). Increased rating for laparotomy scar Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1994). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. Regulations also provide that each disability be viewed, and medical reports pertaining thereto be interpreted, in light of the whole recorded history, and that each disability be considered from the point of view of the veteran working or seeking work. 38 C.F.R. §§ 4.1, 4.2 and 4.10 (1994). The veteran's laparotomy scar is currently evaluated under diagnostic codes 7301-7805. Disabling superficial scars are rated under diagnostic code 7803, if poorly nourished with repeated ulceration, or under diagnostic code 7804 if tender and painful on objective demonstration. 38 C.F.R. Part 4, Codes 7803, 7804 (1994). None of these manifestations having been shown or even contended, the scar has been rated under diagnostic code 7805, which provides that other scars are to be rated on limitation of function of the affected part. 38 C.F.R. Part 4, Code 7805 (1994). Diagnostic code 7301 pertains to adhesions of the peritoneum, and provides that mild adhesions are noncompensable. Moderate adhesions are rated 10 percent disabling; moderately severe adhesions warrant a 30 percent rating; and severe adhesions are rated 50 percent disabling. 38 C.F.R. Part 4, Code 7301 (1994). In addition to the fact that no residual adhesions have been shown since the 1979 surgery, we note that the surgery at that time released the previous adhesions, thought to stem from a ruptured appendix in childhood. Although the veteran believes that his gastrointestinal symptoms result from the laparotomy, the veteran, as a lay person, is not competent to offer evidence of medical causations. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). There is no medical evidence confirming the veteran's viewpoint, and examinations have in fact concluded the opposite, that there is no connection between the laparotomy and any gastrointestinal symptoms the veteran has experienced. Moreover, an exceptional or unusual disability picture has not been presented such as would warrant an extraschedular evaluation under 38 C.F.R. § 3.321(b) (1994). Specifically, there has been no demonstration of marked interference with employment or frequent periods of hospitalization so as to render impractical the application of the regular schedular criteria. Consequently, the preponderance of the evidence is against a compensable evaluation for laparotomy scar. ORDER Service connection for irritable bowel syndrome is granted. Service connection for hiatal hernia is granted. A compensable evaluation for laparotomy scar, post operative incision of abdominal adhesion is denied. (CONTINUED ON NEXT PAGE) JACK W. BLASINGAME Member, Board of Veterans' Appeals 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.