BVA9504979 DOCKET NO. 91-16 318 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for a chronic gastrointestinal disorder or a hiatal hernia as a residual of lye ingestion. 2. Entitlement to an increased evaluation for sinusitis, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: California Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Hal Smith, Counsel INTRODUCTION The veteran served on active military service from November 1943 to July 1946. This appeal arises from rating determinations of the Department of Veterans Affairs (VA) Los Angeles, California, Regional Office (RO). A hearing was held on March 11, 1991, in Los Angeles, California, before S.W. Warner, the undersigned member of the Board section rendering the final determination in this claim and was designated by the Chairman to conduct that hearing, pursuant to 38 U.S.C.A. § 7102(b) (West 1991). In addition to sinusitis, rated as 10 percent disabling, service connection is in effect for anxiety reaction with post-traumatic stress disorder (PTSD), rated as 30 percent disabling. CONTENTIONS OF APPELLANT ON APPEAL Essentially, it is contended that service connection is warranted for a hiatal hernia and that an increased evaluation is warranted for service-connected sinusitis. Specifically, the veteran asserts that he swallowed or inhaled some lye during active service and that this resulted in a burning stomach and gastrointestinal disability which was misdiagnosed as an ulcer. In actuality, it was a hiatal hernia. As for his service- connected sinus disorder, the veteran complains of nasal airway obstruction, headaches and coughing. 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 service connection for a gastrointestinal disorder, to include a duodenal ulcer, gastroesophageal reflux and dysphagia and for a hiatal hernia. The evidence is also against the grant of an increased evaluation for sinusitis. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the veteran's claim has been developed. 2. A duodenal ulcer was first demonstrated several years after service separation and is not related to service. 3. Gastroesophageal reflux, dysphagia or a hiatal hernia were not manifested during the veteran's period of military service, and are not otherwise related to service. 4. Current manifestations of the veteran's sinusitis include erythematous nasal cavities with mucoid drainage; sinus X-ray was interpreted as showing fluid and tissue changes of the maxillary sinuses. CONCLUSIONS OF LAW 1. A duodenal ulcer was not incurred in or aggravated by military service, nor may service incurrence be presumed. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1994). 2. Gastroesophageal reflux, dysphagia or a hiatal hernia were not incurred in or aggravated by military service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303(b) (1994). 3. The criteria for an evaluation in excess of 10 percent for sinusitis have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.102, 3.321, 4.7 and Part 4, Diagnostic Code 6513 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran's claims are well-grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991); that is, he has presented claims which are plausible. Further, we are satisfied that all relevant facts have been properly developed. There is no indication that there are additional records which have not been obtained which would be pertinent to the veteran's claims. Thus, no further assistance is required to comply with the duty to assist as mandated by 38 U.S.C.A. § 5107(a). Godwin v. Derwinski, 1 Vet.App. 419 (1991); White v. Derwinski, 1 Vet.App. 519 (1991). Service Connection for a Chronic Gastrointestinal Disorder or a Hiatal Hernia In part, a grant of service connection requires a demonstration of a current disorder shown to be reasonably attributable to either disease or injury which was incurred in or aggravated by active service. The veteran has related that since he ingested lye when blowing on a fuel line during service, he has experienced an abdominal burning sensation which later resulted in a hiatal hernia. He continues to experience gastrointestinal problems related to this disorder. BACKGROUND A review of the available service medical records, including examinations in January and June 1946, shows that they are negative for any pertinent complaint, finding or history as to a gastrointestinal disorder or a hiatal hernia. On VA examination in June 1948, the veteran gave a history of an abdominal infection in February 1948 but physical examinations in June 1948 and July 1951 were negative for pertinent pathology. Post service records show that an upper gastrointestinal X-ray series was conducted in May 1953 after the veteran gave a one year history of heartburn. The esophagus appeared normal, but the findings of spastic and somewhat deformed duodenal cap and ulcer crater were noted to be consistent with a duodenal ulcer. Additional post service VA records from many years later in 1979 indicate additional gastrointestinal complaints. For example, in February 1979, the veteran was seen for epigastric burning. An upper gastrointestinal X-ray series was interpreted as showing no evidence of hiatus hernia, but there was reflux of gastric content in the lower esophagus and distal esophageal mucosal fold inflammation. Later that year in October, the veteran was seen epigastric symptoms and an upper gastrointestinal X-ray series in November showed hiatal hernia with mucosal prominence of the duodenal bulb but no definite active ulceration. In December 1981, a small hiatal hernia and reflux esophagitis were reported. This hernia was confirmed upon upper gastrointestinal X-ray series in November 1987. In March 1991 at a personal hearing before a travel board section of the Board, the veteran testified in support of his contentions. He provided details as to when he accidentally swallowed lye during service. He reiterated that ever since this occurred, he had experienced a burning sensation in his stomach resulting in a hiatal hernia. He said that he had been treated for gastrointestinal problems in France and in 1953 for a duodenal ulcer. On VA examination in March 1993, the assessments were gastroesophageal reflux disease, status post lye ingestion and dysphagia. In December 1994, in response to a Board request, an independent medical expert, Joel V. Weinstock, M.D., Director, Division of Gastroenterology-Hepatology and Director, Center for Digestive Diseases, at the University of Iowa, addressed the question of whether there was any medical or scientific basis to support the contention that lye ingestion was etiologically related to a hiatus hernia. He also addressed the question as to whether there was an etiologic relationship between the veteran's hiatus hernia and gastroesophageal reflux disease and dysphagia. After review of the veteran's records, the medical expert stated the following: It is my opinion that the patient's hiatal hernia is not the result of lye damage to the esophagus. The patient had a large number of upper GI X-rays performed from 1953 to the present. These X-rays revealed no evidence of esophageal scarring or stricturing that would support the contention of previous severe lye injury. The physician added that hiatal hernias are one of the most prevalent defects in the gastrointestinal tract of the middle to older age population (the veteran was 69 years old). Additionally, the physician provided the following: [P]atients with hiatal hernias are more apt to develop reflux of gastric acid into the esophagus. The reflux of acid results in the sensation of heartburn and can induce dysphagia. Long term exposure and severe exposure to gastric acid can cause esophageal stricturing. He summarized that lye ingestion did not cause the hiatal hernia, clinically documented and confirmed by diagnostic tests in 1979, and he noted that the hiatal hernia and esophageal reflux disease were only casually related. There was no causal relationship between post-traumatic stress or sinusitis and hiatal hernia. ANALYSIS The evidence above is not convincing that the veteran's post service gastrointestinal disorders, to include a duodenal ulcer, gastroesophageal reflux and dysphagia, are of World War II service origin. Neither is it convincing that a hiatal hernia was incurred as a result of in-service ingestion of lye. Clearly, the initial finding of a duodenal ulcer was several years after separation from service in 1953. At that time, the veteran gave a one year history of heartburn and testing did indeed show an ulcer. As stated above, however, the duodenal ulcer was not demonstrated during service (including on examinations in 1946), on VA examinations in 1948 and 1951 or for several years thereafter. Thus, service connection is not warranted for that gastrointestinal disability. Likewise, service connection is not warranted for the recently diagnosed gastrointestinal disorders of gastroesophageal reflux and dysphagia. While the clinical evidence of record does show a long history of post service gastrointestinal complaints, there is no competent evidence or medical opinion which links these problems to any incident of service, and as the service medical records are negative for chronic gastrointestinal complaints or diagnoses, it would be conjecture to conclude that current gastrointestinal diagnoses are the result of military service. We note that the medical expert's statement included the opinion that current gastrointestinal diagnoses (gastroesophageal reflux and dysphagia) were related to the veteran's hiatal hernia, and as explained below, the veteran's hernia is also not of service origin. The veteran's primary contention has been that he was treated during service for gastrointestinal complaints that were misdiagnosed as an ulcer. He argues that a hiatal hernia had its onset during service as a result of lye ingestion. While a review of the service medical records shows that they are apparently incomplete, there simply is no mention on the available records for review of treatment for any gastrointestinal problem during service. This includes at time of discharge examination in January 1946, when the digestive system was noted to be normal. We also note that it was specifically recorded that there was no hernia. Also in support of the determination that the veteran's hiatus hernia is not of service origin, is the independent medical expert's opinion from December 1994. He specifically stated that this disorder is not the result of any lye damage to the esophagus as evidenced by numerous upper gastrointestinal series performed after service which did not show damage to the esophagus. In considering the transcript of the travel board hearing in March 1991, as to this claim, we note that the veteran's testimony is useful in assessing the current and historical complaints and problems, but he is not competent to establish diagnosis or etiology or causation of a gastrointestinal disorder or hiatal hernia. See Espiritu v. Derwinski, 2 Vet.App. 492, 494 (1992). This is a medical question which has been addressed by medical experts in the light of the entire evidentiary record. An Increased Evaluation for Sinusitis Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. The severity of the veteran's sinusitis is assessed by VA for compensation purposes by application of the criteria set forth in Diagnostic Code 6513 of the VA Schedule for Rating Disabilities (Schedule), 38 C.F.R. Part 4. BACKGROUND A brief history of the events preceding this appeal as to this issues is as follows: Service connection for sinusitis was established by rating action in July 1946, and a 30 percent disability evaluation was assigned. The 30 percent rating continued for several years before being reduced by the RO upon rating determination in June 1948. It was reduced to a noncompensable rating by rating decision in October 1953, effective from December 30th of that year. The noncompensable rating continued for many years as sinus X-rays showed no nasal obstruction or active sinusitis in February 1979 or October 1982, and the current appeal ensued following a January 1990 determination which again confirmed and continued the noncompensable rating. During the course of this appeal, however, it was determined that a 10 percent rating was warranted. Upon rating determination in September 1993, a 10 percent evaluation for sinusitis, effective from December 8, 1989, was established. The appeal continues. Under Diagnostic Code 6513, a 10 percent evaluation is warranted for moderate chronic sphenoid sinusitis manifested by a discharge, crusting, or scabbing and infrequent headaches. A 30 percent evaluation is provided when there is severe chronic sphenoid sinusitis manifested by frequently incapacitating recurrences, severe and frequent headaches and a purulent discharge or crusting reflecting purulence. At the personal hearing in March 1991, the veteran related that his sinus disorder resulted in his head always feeling "plugged up" at night. The most current clinical findings are provided by a March 1993 VA examination. At that time, the veteran complained of sinus problems of many years' duration. He said that he had never taken medication for sinus symptoms. Current symptomatology included nasal airway obstruction, headaches in the frontal area and coughing. Examination showed erythematous nasal mucosa with mucoid drainage. The inferior and middle turbinates were swollen and red. X-rays were interpreted as showing fluid in the right maxillary sinus and thickening in the left maxillary sinus. The diagnosis was acute sinusitis. ANALYSIS Based on these findings, the RO determined that a rating of 10 percent was warranted. This grant was effectuated by rating action in September 1993. These clinical findings, however, do not warrant a rating in excess of 10 percent. The degree of severity of symptomatology (frequently incapacitating recurrences, severe and frequent headaches and purulent discharge or crusting reflecting purulence) is not demonstrated. The 10 percent rating recently granted adequately compensates the veteran for current sinusitis symptomatology. The evidence above does not suggest that the veteran's service- connected sinusitis presents such an exceptional or unusual disability picture so as to render impractical the application of the regular schedular standards, so as to warrant the assignment of an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1) (1994), as he has not been frequently hospitalized for treatment of his condition, and the schedular criteria are adequate to rate this disability. Additionally, we do not find that there is a question as to which of two evaluations shall be applied to the veteran's sinusitis. 38 C.F.R. § 4.7 (1994). ORDER Service connection for a gastrointestinal disorder and for a hiatal hernia is denied. An increased evaluation for sinusitis is denied. JAN DONSBACH WILLIAM O. BAILEY, JR., M.D. SAMUEL W. WARNER 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.