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M21-1, Part III, Subpart iv, Chapter 4, Section H – Digestive Conditions


In This Section

This section contains the following topics:
Topic Topic Name


Basic Rating Principles for Digestive Disabilities
2 Hepatitis


Other Digestive Conditions

1. Basic Rating Principles for Digestive Disabilities


This topic contains information about rating digestive system conditions, including

Change Date

January 11, 2018

III.iv.4.H.1.a.  Considering Circumstances of Service Associated With Gastrointestinal Disorders

If the issue is service connection (SC) for dysentery or other gastrointestinal disease, assign great weight to any service under the following conditions since these conditions may have been the etiological or aggravating factor:

  • tropical service
  • imprisonment or internment under unsanitary conditions, or
  • food deprivation.

Reference:  For more information on establishing SC for dysentery and other tropical diseases, see 38 CFR 3.309(b).

III.iv.4.H.1.b.  Prohibition of Separate Evaluations for Certain Coexisting Digestive Disabilities

38 CFR 4.114 specifies that evaluations of digestive conditions under certain diagnostic codes (DCs) will not be combined with each other or assigned separate evaluations.  These are:

  • 7301 to 7329, inclusive (meaning all the DCs from 7301 to 7329)
  • 7331
  • 7342, and
  • 7345 to 7348, inclusive (meaning all the DCs from 7345 to 7348).

III.iv.4.H.1.c.  Evaluating Coexisting Digestive Disabilities

Under 38 CFR 4.113 and 38 CFR 4.114 when there are coexisting digestive disabilities for which multiple evaluations cannot be assigned

  • a single rating will be assigned under the DC which reflects the predominant disability, and
  • that evaluation will be elevated to the next higher evaluation when the severity of the overall disability warrants it.
The Veterans Benefits Management System – Rating (VBMS-R) Evaluation Builder is programmed to appropriately apply the provisions of 38 CFR 4.114 but it is critical that
  • the user input the symptoms that support the elevation, and
  • the symptoms coincide with the criteria listed in the rating schedule.
For instructions on proper application of the 38 CFR 4.114 provision on assigning an evaluation in cases of multiple qualifying coexisting digestive disabilities see the table below.
Determine which of the coexisting digestive conditions is the predominant disability.
  • To determine the predominant disability, determine the evaluation each condition would support on its own.  The condition that has the highest disability evaluation is the predominant disability.
  • If the same evaluation would be assigned to each, go through the analysis in the steps, alternatively treating each condition as the predominant one to see if one alternative provides a more advantageous outcome to the Veteran.
Determine if there are symptoms of the non-predominant disability that do not overlap with those of the predominant disability.
  • If yes, go to Step 3.
  • If no, go to Step 4.
Reevaluate the predominant disability but this time also consider the non-overlapping symptoms of the non-predominant disability.
Important:  The non-overlapping symptoms must support a higher evaluation when applied to the DC criteria being utilized for the predominant disability.
Determine if the resultant evaluation is higher than the evaluation for the symptoms of the predominant disability alone (as derived in Step 1).
  • If yes, go to Step 5.
  • If no, go to Step 4.
  • Rate the coexistent disabilities together under the rating criteria for the predominant disability without elevation to the next higher evaluation.
  • No further action necessary.
  • Rate the coexistent disabilities together under the rating criteria for the predominant disability and elevate to the next higher evaluation.
  • No further action necessary.
Important:  The “next higher level of evaluation” is the lowest evaluation specified in the DC for the predominant disability that provides greater compensation than the evaluation derived in Step 1 (the evaluation that would be supported by only the symptoms of the predominant disability without the symptoms of the lesser disability).  Do not simply add 10 percent.

III.iv.4.H.1.d.  Example  – Evaluating Coexisting Digestive Disabilities

Situation:  A Veteran has two coexisting digestive conditions:
  • duodenal ulcer meeting the criteria for a 20-percent evaluation under 38 CFR 4.114, DC 7305 (a moderate case with episodes of recurring symptoms several times a year), and
  • ulcerative colitis, meeting the criteria for a 30-percent evaluation under 38 CFR 4.114, DC 7323 (a moderately severe cases with frequent exacerbations).
Result:  Separate evaluations for the duodenal ulcer and ulcerative colitis are notpermitted under 38 CFR 4.114.  A single 30-percent evaluation under 38 CFR 4.114, DC 7323 would be assigned as ulcerative colitis represents the predominant disability picture.
There are no non-overlapping symptoms of duodenal ulcer to establish any of the criteria for which the next higher (60 percent) evaluation could be assigned for ulcerative colitis:  severe with numerous attacks a year and malnutrition, health only fair during remissions.  Therefore elevation is not appropriate.
Situation:  A Veteran has two coexisting digestive conditions:
  • irritable bowel syndrome, meeting the criteria for a 10-percent evaluation analogously under 38 CFR 4.114, DC 7319 (moderate with frequent episodes of bowel disturbance with abdominal distress)
  • hiatal hernia, meeting the criteria for a 10-percent evaluation under 38 CFR 4.114, DC 7346 (with persistently recurrent epigastric distress with dysphagia and pyrosis without substernal or arm or shoulder pain and without considerable impairment of health)
Result:  Separate evaluations for irritable bowel syndrome and hiatal hernia arenot permitted under 38 CFR 4.114.  A single 10-percent evaluation under either DC is permissible since neither condition is predominant.  However, assignment of 38 CFR 4.114, DC 7346 is recommended because this DC allows for a greater evaluation for any future claims for increase.
There are no non-overlapping symptoms to establish any of the criteria for which the next higher evaluation could be assigned when comparing both conditions as the predominant disability as described in M21-1, Part III, Subpart iv, 4.H.2.c.  Therefore elevation is not appropriate.

2.  Hepatitis


This topic contains information about hepatitis, including

Change Date

January 11, 2018

III.iv.4.H.2.a.Categories of Hepatitis Recognized for Rating Purposes

There are three categories of hepatitis recognized for rating purposes.  The table below describes each type of hepatitis and explains the transmission and prognosis for each.

Type of Hepatitis



hepatitis A Virus (HAV), previously called infectious hepatitis fecal-oral route
acute—seldom severe and does not leave residuals
Note:  In order to award SC, there must be evidence of chronic residuals related to the hepatitis A infection.
hepatitis B Virus (HBV), previously called serum hepatitis
  • blood products
  • sexual contact
  • acute in 90-95 percent of cases, but acute disease can be severe and result in death
  • chronic in 5-10 percent of cases
  • Cirrhosis and liver cancer may develop.
  • A vaccine to prevent HBV infection is available.
hepatitis C (HCV), previously called non-A non-B hepatitis infected blood
  • clinically asymptomatic acute disease
  • Chronic disease develops in 80 percent of cases following acute phase.
  • Diagnosis is generally made incidentally many years later.
Note:  Infectious hepatitis is common throughout the world and was especially prevalent during World War II following administration of the yellow fever vaccine in 1942 and in the Mediterranean Theater.
Reference:  For more information on risk factors for HBV and HCV, see M21-1, Part III, Subpart iv, 4.H.2.e.

III.iv.4.H.2.b.Diagnostic Testing Required for Hepatitis

SC for hepatitis requires blood serology testing to establish a diagnosis and identify the type of hepatitis present.  Liver function tests (LFTs) are necessary to assess the severity of the disease.
  • The rating decision should always specify the type of hepatitis for which SC is awarded.
  • Serological tests determine the presence of antigens and antibodies to the specific virus.  The presence of antibodies to the specific virus indicates the infection is present.
The table below describes types of serological testing required to confirm a diagnosis for each type of hepatitis.

Type of Hepatitis

Serology or Other Testing Required

Additional Notes

HAV anti-HAV (antibodies to hepatitis A virus)
  • Anti-HAV are present in the blood one month after the acute illness and persist for life.
  • Serological blood testing showing the presence of anti-HAV indicates a past acute infection.
  • anti-HBsAg (hepatitis B surface antigen) is present during the acute phase.
  • HBsAg that persists more than three to six months indicates probable chronic disease or carrier status.
  • A positive Australian antigen test is sufficient to confirm hepatitis B.


HBV has two antigens, a surface antigen and a core antigen

  • HBsAg, and
  • HBcAg (hepatitis B core antigen).

Consequently, two types of antibodies appear in the blood

  • anti-HBs (antibodies to the surface antigen), and
  • anti-HBc (antibodies to the core antigen).
  • EIA (enzyme immunoassay) or ELISA (enzyme linked immunosorbent assay, also called Western blot) is the first test.
  • If EIA or ELISA is positive, RIBA (recombinant immunoblot assay) is needed to confirm the diagnosis of chronic HCV.
  • In lieu of EIA/ELISA followed by RIBA, a positive test for HCV RNA (hepatitis C viral ribonucleic acid) is sufficient by itself to confirm a diagnosis of HCV.
  • HCV RNA results can be
    • qualitative (positive or negative), or
    • quantitative (number of copies per milliliter (ml)).
The presence of anti-HCV (including EIA or ELISA) isnot sufficient for a diagnosis of chronic HCV because it can be present in other diseases.
Note:  Liver biopsy, ultrasound, and computed tomography (CT) scan tests can detect damage to the liver but will not identify the type of infection.

III.iv.4.H.2.c.Interpreting Lab Reports for HBV

The table below provides an example of a laboratory interpretation of serology test results for HBV.
Test Results Interpretation
Example 1
HBsAg negative susceptible to infection
anti-HBc negative susceptible to infection (no hepatitis B)
anti-HBs negative no history of hepatitis B
Example 2
HBsAg negative immune
anti-HBc negative or positive immune
anti-HBs positive
Example 3
HBsAg positive acute infection
anti-HBc positive
Immunoglobulin M (IgM) anti-HBc positive acute infection
anti-HBs negative
Example 4
HBsAg positive chronic infection
anti-HBc positive
IgM anti-HBc negative chronic infection
anti-HBs negative

III.iv.4.H.2.d.Interpreting Lab Reports for HCV After 1992

The table below provides an example of a laboratory interpretation of serology testing for HCV for testing performed after 1992.
Tests Results Interpretation
anti-HCV positive (probable chronic hepatitis) need to verify diagnosis
EIA positive supplemental test required
RIBA positive diagnostic
HCVRNA follow-up of chronic hepatitis C not needed for rating

III.iv.4.H.2.e.  Risk Factors for HBV and HCV

Risk factors for the development of HBV and HCV are similar.  The table below describes the medically recognized risk factors for HBV and HCV infection, provides transmission information concerning those risk factors, and includes tips for confirming the risk factors.
Note:  Resolve reasonable doubt under 38 CFR 3.102 in favor of the Veteran when the evidence favoring risk factor(s) in service is equal to the evidence favoring risk factor(s) before or after service.

Risk Factor

Transmission Information

Rating Tips

  • transfusion of blood or blood product
    • before 1992 for HCV, or
    • before 1975 for HBV
  • organ transplant before 1992, or
  • hemodialysis
  • Blood donor screening for HCV was not available until 1989 when HCV was identified.
  • In 1992, more effective screening of blood became possible for HCV.
  • If blood transfusion is a claimed risk factor, obtain the relevant hospital records from service, if possible.
  • Look for evidence of blood transfusions in surgical reports, especially the
    • anesthesia sheet
    • surgical record
    • operative clinical records, or
    • post-operative clinical notes.
  • tattoos
  • body piercing, and
  • acupuncture with non-sterile needles
transmitted through the use of unsterilized equipment Review for indications of tattoos or piercings on induction and separation exams to help determine whether tattooing or piercing took place in service.
intravenous drug use transmitted through the use of shared instruments Records of drug treatment may reflect the type of drug abuse.
high-risk sexual activity Transmission risk is relatively low but increases with multiple sexual partners. Periodic health assessments or records of treatment for sexually transmitted diseases may document a history of high-risk sexual activity or multiple sexual partners.
intranasal cocaine use transmitted through the use of shared instruments Records of drug treatment may reflect the type of drug abuse.
accidental exposure to blood by percutaneous exposure or on mucous membranes common for the following:

  • health care workers
  • combat medics, and
  • corpsmen
Consider service department or other records reflecting occupational history.
sharing of

  • toothbrushes, or
  • shaving razors
transmitted through direct percutaneous exposure to blood This type of in-service exposure will not generally be documented in service records. Consider buddy statements in the context of the entire evidence picture pertaining to risk factors.
immunization with a jet air gun injector
  • onedocumented case of HBV transmission
  • Despite the lack of any scientific evidence to document transmission of HCV with air gun injectors, it is biologically possible.
A medical report linking hepatitis to air gun injectors must include a full discussion of all potential modes of transmission and a rationale as to why the examiner believes the air gun injector was the source for the hepatitis infection.

III.iv.4.H.2.f.Development for Hepatitis Risk Factors

As Department of Veterans Affairs (VA) Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, does not inform the claimant to submit evidence of hepatitis risk factors, development for risk factors is required in every hepatitis claim, even when hepatitis is diagnosed in service.  Development is necessary to determine if pre- and post-service risk factors are present as well as to ensure that the risk factor is not substance abuse either before or during service.
Regardless of what claim form the Veteran submits, development for risk factors is required if the complete risk factor history has not already been provided.  If risk factor history is not of record, use the table below to develop to the Veteran.
If the Veteran is claiming … Then generate a risk factors development letter in …
hepatitis C VBMS.
  • hepatitis A or B, or
  • a non-specific form of hepatitis
  • Modern Award Processing-Development (MAP-D), and
  • alter the letter to specify the type of hepatitis claimed by the Veteran (A, B, or none).
References:  For more information on

III.iv.4.H.2.g.Considering Drug Abuse in Hepatitis Claims

If one of the risk factors for hepatitis is intravenous or intramuscular drug use, or intranasal cocaine use, do not automatically assume the substance abuse is the cause of hepatitis and deny the claim on that basis.
Follow the steps in the table below when considering a claim for SC for hepatitis in which injection drug or intranasal cocaine use is a confirmed in-service risk factor.




Review for all risk factors of hepatitis in addition to the drug use.


If injection drug or intranasal cocaine use is the only confirmed in-service risk factor present, then deny SC. If other in-service risk factors are found in addition to injection drug or intranasal cocaine use, go to Step 3.


Request a medical opinion to determine which confirmed in-service risk factor is at least as likely as not the cause of the hepatitis infection.


Use the table below to determine how to proceed with the medical opinion.
If the medical opinion … Then …
states that drug use is the cause of the hepatitis infection deny the claim for SC for hepatitis.
gives greater or equal weight to another confirmed in-service risk factor
  • resolve reasonable doubt in the Veteran’s favor, and
  • award SC.
is unable to state which risk factor is more likely than not to be the cause of the hepatitis
  • weigh all evidence, and
  • apply the reasonable doubt doctrine if the evidence is found to be in equipoise.

Reference:  For more information on examiner statements that an opinion would be speculative, seeM21-1, Part III, Subpart iv, 3.D.2.r.

Reference:  For more information on considering claims for SC based on drug use, see

III.iv.4.H.2.h.  Evaluating Claims for Increase for SC Hepatitis Awarded Due to Drug Abuse

Follow the steps in the table below to determine the appropriate actions to take in a claim for increase when SC was previously awarded but the only apparent risk factor in service was drug abuse.




Was SC for hepatitis due to drug abuse awarded by rating decision on or before October 31, 1990?

  • If yes, then continue the finding of SC for hepatitis as the award of SC was proper based on regulations and procedures at that time. Go to Step 5.
  • If no, then go to Step 2.


Does the evidence clearly show that the hepatitis is due to in-service drug abuse?

  • If yes, go to Step 4.
  • If no, go to Step 3.


If SC was awarded but there is no evidence clearly linking the hepatitis to drug abuse or if there were multiple risk factors in service, one of which was drug abuse, and no prior opinion was obtained, request a medical opinion to determine whether the hepatitis is due to the drug abuse.

If the resulting opinion

  • clearly links hepatitis to drug abuse, go to Step 4.
  • cannot resolve whether hepatitis is due to drug abuse or another in-service risk factor, or the hepatitis is attributed to another non-drug abuse in-service risk factor, then
    • resolve reasonable doubt in favor of the Veteran and continue the finding of SC, and
    • award an increased evaluation for hepatitis if the medical evidence otherwise shows the increase is warranted.


If the evidence clearly shows that the hepatitis is due to in-service drug abuse and SC was awarded by rating decision after October 31, 1990, determine whether the award of SC is protected per 38 CFR 3.957.

  • If SC. is protected, go to Step 5.
  • If SC is not protected, then propose to sever SC per 38 CFR 3.105(a).


If SC was properly established for hepatitis due to drug abuse by rating decision on or before October 31, 1990, and/or if the award of SC for hepatitis is protected, do not award an increased evaluation for hepatitis due to drug abuse.
  • The Omnibus Reconciliation Act of 1990 (Public Law 101-508 Section 8052) prohibited the grant of SC for disability or death resulting from alcohol or drug abuse for claims filed after October 31, 1990.
  • VAOPGCPREC 2-1998 found that an increased evaluation may not be awarded when SC was previously properly established as due to drug abuse by rating decision on or before October 31, 1990.

Considering In-Service Hepatitis Findings

When a Veteran submits a claim for SC of hepatitis, assess the lay evidence, service treatment records (STRs), and current medical records to ascertain whether a current disability, an in-service event or injury, and an indication of an association are present as required in 38 CFR 3.159(c)(4) prior to requesting examination and/or medical opinion.
Use the table below to determine the proper rating action for in-service findings related to hepatitis.
If STRs show … Then …
diagnosis of non-specific hepatitis and SC is claimed many years later request an exam with serology testing and LFTs (if not already of record) and opinion to determine if a relationship exists between the episode of hepatitis in service and the current type of hepatitis unless there is sufficient evidence of a clearly-established diagnosis and continuous symptoms present to satisfy the nexus standard under 38 CFR 3.303(a).
laboratory findings confirming HAV or HBV do not automatically service connect HCV since each type of hepatitis can be acquired at different times and through different means.


  • SC for HAV is not warranted as HAV is an acute condition.
  • Consider SC for HBV if a chronic disability is present and linked to the in-service finding and/or risk factors.
  • Consider SC for HCV if a medical opinion links the condition to the confirmed in-service findings and/or risk factors.
a diagnosis of non-A, non-B hepatitis (old name for hepatitis C) and the current medical evidence confirms a diagnosis of HCV SC is likely warranted.

  • If medical evidence establishes the presence of continuous symptoms since service, then award SC.
  • If evidence of continuous symptoms since service is not present, request a nexus opinion.
non-specific hepatitis and current evidence shows HCV or chronic HBV only
HCV or chronic HBV may warrant SC based on reasonable doubt. Request a medical opinion and any necessary diagnostic testing to confirm the diagnosis.
Reference:  For more information on diagnostic testing required for hepatitis, see M21-1, Part III, Subpart iv, 4.H.2.b.
non-specific hepatitis and current evidence shows HCV or chronic HBV as well as a history of HAV a medical opinion is necessary to determine whether the current disability is a result of the non-specific hepatitis diagnosed in service.

III.iv.4.H.2.j.Requesting Exams and/or Opinions for HBV or HCV

Follow the steps in the table below when requesting an examination and/or opinion for HCV or chronic HBV.
Step Action


Identify and request the examiner review of all relevant evidence in the claims folder.


List any risk factors identified by the Veteran.


Identify all risk factors confirmed by the evidence in the claims folder, whether claimed by the Veteran or not.

Important:  In addition to in-service risk factors, ensure that all documented pre- and post-service risk factors are noted in the exam request.


Request VA Form 21-0960G-5, Hepatitis, Cirrhosis And Other Liver Conditions Disability Benefits Questionnaire (DBQ), which will include diagnostic testing as well as LFTs and a detailed description of clinical findings and reported symptoms.


Request a medical opinion about the relationship between the current HBV or HCV infection and confirmed or supported risk factor(s).


Notify the examiner that a positive nexus opinion, if warranted, should take only confirmed risk factors as shown by the objective evidence of record into consideration.
References:  For more information on

III.iv.4.I.2.k.Reviewing Hepatitis Exams and Opinions for Sufficiency

Review the examination or opinion to ensure sufficiency and return insufficient examinations when warranted.  Common reasons for insufficient examinations are

  • lack of proper confirmatory testing to support the diagnosis
  • failure to include complete clinical findings and symptoms in the report
  • failure to address all known risk factors in the opinion
  • opinions linking HCV or chronic HBV to a risk factor that is not confirmed in the evidence of record, and
  • opinions improperly linking HCV or chronic HBV to a risk factor that is not medically recognized as a source of infection.

III.iv.4.I.2.l.Assigning a 0-Percent Evaluation for HCV

A 0-percent evaluation should only be assigned for HCV when the condition is asymptomatic and the infection has healed.
Use the table below to determine when it is appropriate to assign a 0-percent evaluation for HCV.
If medical evidence shows … Then a 0-percent disability evaluation is …
even mild symptoms related to HCV infection not appropriate because the Veteran is symptomatic.
there is evidence of liver damage on liver function tests, liver biopsy, or other testing not appropriate because this means the infection is not healed.
HCV has responded to therapy to the extent that RNA test results are negative and the Veteran is now asymptomatic with no evidence of liver damage appropriate. However, HCV remains dormant in the system and may flare up again later.
Reference:  For additional information on evaluation of HCV, see 38 CFR 4.114, DC 7354.

3.  Other Digestive Conditions


This topic contains information about other digestive disabilities, including

Change Date

January 11, 2018

III.iv.4.H.3.a.  Establishing SC for Inguinal Hernia

Do not assume the preexistence of a hernia.  Determine preexistence on a factual basis.
The following conditions are sufficient bases for SC:
  • in-service initial manifestation of hernial protrusion, and
  • recurrence during service, by aggravation, of a hernia previously surgically repaired.
Note:  Operation for repair of a preexisting inguinal hernia is not necessarily evidence of aggravation.
Reference:  For information on the presumption of soundness at entrance into service, see 38 CFR 3.304(b).

III.iv.4.H.3.b.  SC and Recurrence of Hemorrhoids

Initial awards of SC for hemorrhoids are governed by customary rules for SC included in 38 CFR 3.303.
After SC is initially established, unless the award of SC for hemorrhoids was in error, consider recurrences after a period of absence of hemorrhoids post-service to be associated with the service-connected (SC) condition rather than a nonservice-connected superseding condition.
Reference:  For more information on reversing an erroneous decision, see

III.iv.4.H.3.c.  Example: Analyzing Recurrence of Hemorrhoids

Situation:  SC is established for hemorrhoids first diagnosed during service. A 0-percent evaluation was assigned under 38 CFR 4.114, DC 7336 for mild external hemorrhoids.
Two years after SC was granted for hemorrhoids, the Veteran filed a claim for increased evaluations for all of his SC conditions.  Examination showed no hemorrhoids.  The diagnosis was “hemorrhoids, not shown.”  The 0-percent evaluation was continued.
Five years later the Veteran filed a claim for an increased evaluation for hemorrhoids.  Records showed several instances of doctor visits in the last year for external hemorrhoids.  The Veteran reported a history of “old” problems with hemorrhoids and recent symptoms including bright red blood noted with defecation and discomfort with protracted sitting in his current job.  VA examination reported a similar history and showed external hemorrhoids that were large and irreducible with redundant tissue.  The diagnosis was “hemorrhoids.”
Result:  Assign a 10-percent evaluation.  The facts suggest that the SC hemorrhoids were non-disabling, or even absent, for years after SC was initially granted.  The facts may also suggest that the current symptoms could be independently due to a superseding post-service cause.  However, do not treat them as due to a post-service cause or return the examination for comment on that question.  Treat current hemorrhoids as a recurrence or continuation of the chronic hemorrhoids that were properly SC in the past.

III.iv.4.H.3.d.  Other Causes of Liver Damage

The table below describes recognized causes of liver damage and provides examples of each cause.

Cause of Liver Damage


Infection Virus
Systemic diseases Lupus
  • Isoniazid
  • Acetaminophen
  • Phenytoin
Toxic substances Alcohol

III.iv.4.H.3.e.  Fatty Liver

Fatty liver, also called hepatic steatosis, is not a disability for which SC can be granted.  By itself it is simply considered an abnormal laboratory finding.
Reference:  For more information on abnormal laboratory findings discovered in STRs without a claim, see M21-1, Part IV, Subpart ii, 2.A.2.f.

III.iv.4.H.3.f.  Evaluating Ileostomy

When a SC disability requires treatment with ileostomy, consider analogous evaluation under 38 CFR 4.114, DC 7333 with the requirement for colostomy based on the comparable functions affected.
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