Case presentation A 50-year-old male with a 6-month history of persistent epigastric pain, weight loss, and altered bowel habit is referred to a surgeon. The patient informed that his stools are bulky, pale, and have an unpleasant smell. In addition, he has lost weight due to his poor appetite. He is a chronic smoker and alcoholic and has received treatment for alcohol dependence.

Physical examination The patient is pale, thin, and untidy. There is no jaundice or supraclavicular lymphadenopathy. The abdomen is soft and non-tender with no palpable masses or organomegaly. Laboratory investigation Hb: 13 g/dl                                                    MCV: 108 fl WBC: 10 x 10 9 /L                                          Platelets: 210 x 10 9 /L Sodium: 137 mEq/L                                    Potassium: 3.6 mEq/L Creatinine: 1.27 mg/dl                                Urea: 36…