GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Summary

The veteran, who served in the United States Army from March 1978 to March 1982, appeals the denial of service connection for a gastrointestinal disability, specifically GERD and hiatal hernia. The veteran contended that this gastrointestinal disability was secondary to his service-connected acquired psychiatric disability, including prescribed medications, or alternatively, that his psychiatric condition led to weight gain which caused the gastrointestinal issues. The claim also raised a theory of secondary service connection to his service-connected left knee, right hip, and low back disabilities. The Board reviewed evidence including the veteran's service treatment records, which showed a complaint of digestive issues in 1980, and noted his service connection for adjustment disorder, left knee, back, and right hip disabilities. The Board considered a private PA-C opinion suggesting GERD was at least as likely as not secondary to his psychiatric condition and medications, but found the opinion too general and lacking specific evidence linking the medication to GERD, also noting the presence of H. pylori as a common cause of GERD. Multiple VA opinions from October 2021, December 2021, and October 2022 collectively opined that it was less likely than not that the GERD was caused or aggravated by his psychiatric disability or medications, citing a lack of medical literature supporting a causal relationship and noting GERD and hiatal hernia were diagnosed years after service. A September 2022 VA opinion addressed direct service connection, finding the in-service gastroenteritis complaint inconsistent with GERD and that the later diagnoses could not be linked to service. The Board afforded high probative value to the VA opinions, finding the evidence outweighed the veteran's contentions and that the benefit of the doubt doctrine was not applicable as the preponderance of the evidence was against the claim. Service connection for the gastrointestinal disability was denied.

Rationale

Multiple VA opinions found less likely than not that GERD was caused or aggravated by psychiatric disability or medications.; Private opinion was too general and lacked specific evidence linking medication to GERD.; VA opinions noted common causes of GERD like hiatal hernia and H. pylori, and that GERD predated psychiatric diagnosis.; Board found VA opinions probative due to medical reasoning and specific reference to service history.

Full Decision Text

Citation Nr: A25021976
Decision Date: 03/11/25	Archive Date: 03/11/25

DOCKET NO. 230703-358926
DATE: March 11, 2025

ORDER

Service connection for a gastrointestinal disability, to include gastroesophageal reflux disease (GERD) and hiatal hernia, to include as secondary to service-connected orthopedic and psychiatric disabilities, to include medications prescribed therefor is denied.

FINDING OF FACT

The Veteran's gastrointestinal disability, including GERD and hiatal hernia, is not related to any injury, disease, or event incurred in service, or to the service-connected orthopedic and acquired psychiatric disabilities, to include medications prescribed therefor.

CONCLUSION OF LAW

The criteria for service connection for a gastrointestinal disability, including GERD and hiatal hernia to include as secondary to service connected orthopedic and psychiatric disabilities, and medications prescribed therefor on direct and secondary theories of entitlement have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had active military service in the United States Army from March 1978 to March 1982.

In the appealed Appeals Modernization Act (AMA) May 2023 rating action, the Agency of Original Jurisdiction (AOJ) found that new and relevant evidence had been received to readjudicate the claim for service connection for a gastrointestinal disability, and denied the claim on the merits. In the July 2023 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the May 2023 rating decision. 38 C.F.R. § 20.301.

The Veteran seeks service connection for a gastrointestinal disability. He contends that he currently has a gastrointestinal disability that is secondary to his service-connected acquired psychiatric disability, to include medications (e.g., Buspar) prescribed therefor.  He alternatively contends that his psychiatric disability caused him to gain weight, which, in turn, caused him to develop a gastrointestinal disability. See VA Form 21-4138, Statement in Support of Claim, received in August 2022.  The evidence of record also raises a theory of the entitlement to service connection for a gastrointestinal disability as secondary to service-connected left knee, right hip, and low back disabilities. See May 2023 VA opinion. 

Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. § 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004).

Service connection also may be established on a secondary basis for disability that is proximately due to, or the result of, or being aggravated by a service-connected disability. Establishing secondary service connection requires evidence of: (1) a current disability (for which secondary service connection is sought); (2) an already service-connected disability; and (3) indication the current disability was either (a) caused or (b) is being aggravated by the service-connected disability. See 38 C.F.R. § 3.310 (a) and (b); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc).

In Walsh v. Wilkie, moreover, the United States Court of Appeals for Veterans Claims (Court) held, that the Board needs to consider the obesity-intermediate step theorem predicated on aggravation where appropriate. Thus, the Court held that proper interpretation of G.C. Prec. Op. 1-2017 requires consideration of both proximate causation and aggravation in its analytical framework: (1) whether the service-connected disability (caused the veteran to become obese/aggravated the veteran's obesity); (2) if so, whether the (obesity/aggravation of obesity) as a result of the service-connected disability was a substantial factor in causing the current disability; and (3) whether the current disability would not have occurred but for (obesity caused/obesity aggravated) by the service-connected disability. If these questions are answered in the affirmative, then the current disability may be service connected on a secondary basis. Walsh v. Wilkie, 32 Vet. App. 300 (2020).

The AOJ made the favorable findings identified in the
 proximate causation and aggravation in its analytical framework: (1) whether the service-connected disability (caused the veteran to become obese/aggravated the veteran's obesity); (2) if so, whether the (obesity/aggravation of obesity) as a result of the service-connected disability was a substantial factor in causing the current disability; and (3) whether the current disability would not have occurred but for (obesity caused/obesity aggravated) by the service-connected disability. If these questions are answered in the affirmative, then the current disability may be service connected on a secondary basis. Walsh v. Wilkie, 32 Vet. App. 300 (2020).

The AOJ made the favorable findings identified in the appealed May 2023 rating decision: (i) The Veteran has been diagnosed as having GERD, according to a 2022 VA examination report; (ii) the Veteran's service treatment (STRs) from 1980 show a complaint of digestive issues; and, (iii) the Veteran is service connected for adjustment disorder, a left knee disability, a back disability, and a right hip disability. 

The question that remains in this case is whether there is an etiological relationship between the Veteran's service and/or service connected psychiatric and/or orthopedic disabilities, or the medications prescribed therefor and his GERD. 

The Board will first address the secondary service connection theory of the claim. At the outset, it is noted that there is a single private opinion which supports service connection and multiple VA opinions which explain why it is felt that service connection is not warranted for GERD. 

Evidence in support of the claim is an August 2022 opinion, authored by C.M.B., PA-C. C.M.B. opined, after a review of the Veteran's service and post-service medical records and medical literature, that it was at least as likely as not (50 percent probability) that the Veteran's GERD is secondary to, related to, and/or aggravated by his service-connected psychiatric disorder and medications prescribed therefor. In support of his conclusion, C.M.B. stated that the Veteran's GERD had been diagnosed after his psychiatric condition. 

However, while the opinion suggests that current medical literature supports a nexus between mental health disorders with medications and the development of GERD, the PA did not actually submit any evidence of the Veteran's mental health medication, buspirone, causing GERD. 

The PA's conclusion was that the GERD was caused, and/or aggravated, which seems to be equivocal here, and fails to delve into the intricacies of the specific facts of the Veteran's case.  While the opinion generically suggests that sleep disorder can cause GERD, or that mental health disorders can cause GERD, the provided rationale is far too general to conclude that it is at least as likely as not (approximate balance or nearly equal) that the Veteran's GERD was caused or aggravated by any service connected disability.

The opinion also fails to account for the presence of H. pylori in the Veteran, which the VA opinions note is a very common cause of GERD.  

VA has obtained a number of medical opinions to address the etiology of the Veteran's GERD.  There are a number of VA opinions that are against the secondary service connection theory of the claim. The October 2021, December 2021, and October 2022 VA opinions all collectively opined that it is less likely than not that the Veteran's GERD was either caused or aggravated by his psychiatric disability, to include his medications prescribed therefor (October 2022). The VA examiners supported their opinion with medical rationale that the conditions of the esophagus (including GERD & Hiatal Hernia) and adjustment disorder with mixed anxiety and depressed mood and acquired psychiatric are not medically related. To this end, the October 2021 VA examiner explained that the Esophagus (including GERD & Hiatal Hernia) is a separate entity entirely from the adjustment disorder with mixed anxiety and depressed mood and acquired psychiatric and unrelated to it. A thorough review of medical literature failed to demonstrate a causal relationship. A nexus has not been established.

The December 2021 VA examiner indicated that a review of literature shows that GERD is a problem of impaired lower esophageal sphincter usually caused by motor abnormalities or anatomic causes such as obesity and hiatal hernia. According to the examiner, medical literature shows that GERD is developed when detrimental to the esophagus factors transcend protective mechanisms, such as the esophago-gastric junction barrier and esophageal acid clearance, which normally contribute to the maintenance of a physiologically balanced condition. The examiner stated that there are multiple mechanisms involved in the pathogenesis of GERD including: (1) motor abnormalities, such as impaired lower esophageal sphincter (LES) resting tone, transient LES relaxations
 established.

The December 2021 VA examiner indicated that a review of literature shows that GERD is a problem of impaired lower esophageal sphincter usually caused by motor abnormalities or anatomic causes such as obesity and hiatal hernia. According to the examiner, medical literature shows that GERD is developed when detrimental to the esophagus factors transcend protective mechanisms, such as the esophago-gastric junction barrier and esophageal acid clearance, which normally contribute to the maintenance of a physiologically balanced condition. The examiner stated that there are multiple mechanisms involved in the pathogenesis of GERD including: (1) motor abnormalities, such as impaired lower esophageal sphincter (LES) resting tone, transient LES relaxations (TLESR), impaired esophageal acid clearance and delayed gastric emptying; and (2) anatomical factors, such as hiatal hernia and obesity.  A valve mechanism exists between the esophagus and the stomach, formed by the LES and its adjacent anatomical structures, including the gastric sling and the crural diaphragm [11]. The main role of this valve mechanism in resting conditions is to create a fine-tuned high-pressure zone (15-30 millimeter Hg above intragastric pressures), preventing gastric contents reflux. See December 2021 VA opinion. 

In an October 2022 VA opinion, the VA examiner specifically addressed the August 2022 private clinician's opinion and pointed to evidence that clearly showed that the Veteran's GERD and hiatal hernia were diagnosed prior to the service-connected psychiatric disability, thus, the Veteran's adjustment disorder with mixed anxiety and depressed mood with medication could not have been caused by the medication that was prescribed for his service connected mental health condition. See October 2022 VA opinion, 

In May 2023, a VA examiner provided an opinion that addressed the direct and aggravation components of the secondary service connection of the claim, as well as a discussion of obesity from the Veteran's service connected conditions. To this end, the VA examiner opined that it was less likely than not that the Veteran's GERD and hernia were aggravated beyond its natural progression by the service connected adjustment disorder with mixed anxiety and depressed mood. The VA examiner noted that the Veteran had had anatomical risk factors for the development of GERD to include his hiatal hernia. According to the examiner, a hiatal hernia is a condition in which part of the stomach pushes up through the diaphragm muscle which can cause a predisposition for the development of GERD and, therefore, the Veteran's GERD could not have been aggravated beyond its natural progression by his adjustment disorder with mixed anxiety and depressed mood or medications related to this condition. Overall, according to the May 2023 VA examiner, there was no evidence to suggest that the Veteran's GERD had been aggravated by his service connected musculoskeletal conditions. Regarding the Veteran's claim that his acquired psychiatric medications caused him to become less active and developed obesity which, in turn, led to his GERD, the May 2023 VA examiner specifically concluded that there was no evidence of obesity nor that the service-connected right hip disability, to include medication prescribed therefore, had caused the Veteran to become obese. The May 2023 VA examiner further opined that the Veteran had no evidence of obesity, thus, there was no evidence to support a finding that his medication for his mental condition caused him to become obese nor is there evidence of obesity due to or aggravated by adjustment disorder causing the Veteran's GERD. See May 2023 VA opinion. 

The Board finds these collective VA opinions probative because they adequately addressed the etiological relationship between the Veteran's GERD and service-connected psychiatric and orthopedic conditions, to include medications prescribed therefor, as well as the role of obesity, in the developed of the Veteran's GERD and hiatal hernia. The opinions are supported with medical reasoning and, more importantly, cite specifically to the Veteran's service history and experiences. Specifically, the May 2023 VA examiner considered the role of obesity as an intermediate step between GERD and the Veteran's acquired psychiatric disorder as laid out in Walsh, and found that there was no evidence of obesity in the Veteran. Thus, for these reasons, the Board finds the October 2021, December 2021, October 2022 and May 2023 VA examiners' collective opinions to be of high probative value evidence against the claim for service connection for GERD and hiatal hernia on a secondary basis. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). These opinions are therefore being afforded great probative weight.

The Board will now turn to adjudicating the claim for service connection for GERD and hi
, and found that there was no evidence of obesity in the Veteran. Thus, for these reasons, the Board finds the October 2021, December 2021, October 2022 and May 2023 VA examiners' collective opinions to be of high probative value evidence against the claim for service connection for GERD and hiatal hernia on a secondary basis. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). These opinions are therefore being afforded great probative weight.

The Board will now turn to adjudicating the claim for service connection for GERD and hiatal hernia on a direct service connection theory of entitlement. There is one VA opinion that addresses this theory of entitlement, and it is against the claim. In September 2022, a VA examiner opined, after a review of the record, that it was less likely than not the Veteran's medical record supported a relationship between any currently diagnosed conditions, to include the diagnosis of hiatal hernia, gastroesophageal reflux disease, H. pylori was incurred in or caused by the gastroesophageal reflux disease during service. After noting that the Veteran was seen for complaints of gastroenteritis with vomiting in March 1979, the examiner opined that this finding was not consistent with a diagnosis of GERD, and that the current diagnoses of gastroesophageal reflux disease, H. pylori and hiatal hernia were diagnosed many years after active duty service, thus, a nexus could not be established. See September 2022 VA opinion. The September 2022 VA opinion is considered to be highly probative evidence against the claim on a direct service connection theory of entitlement. The VA examiner considered the Veteran's reported history and provided a sufficient explanation for his opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is no competent opinion of record in favor of the direct service connection theory of the claim. 

With regard to the Veteran's own contentions, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case it falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In this regard, the Veteran is claiming service connection for a gastrointestinal disability, and this is not the type of condition that is readily amenable to mere lay diagnosis or probative comment regarding its etiology. Id; Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The issue on appeal is based on the contention that his gastrointestinal disability, currently diagnosed as GERD and hiatal hernia, are related to an in-service incident or service-connected disability, notably psychiatric and orthopedic disabilities and medications prescribed therefor. The Veteran's service treatment reports and post-service medical records have been discussed. Etiological opinions have been obtained that weigh against the direct and secondary service connection theories of the claim. Given the foregoing, the Board finds that the medical evidence outweighs the Veteran's contentions to the effect that she has the claimed condition due to her service, or a service-connected disability. Madden v. Gober, 125 F. 3d 1477, 1481 (Fed. Cir. 1997).

The Board has considered the doctrine of reasonable doubt, however, as is stated above, the preponderance of the evidence is against the Veteran's claim, and the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

 

 

MATTHEW W. BLACKWELDER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Carole Kammel, Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.