A 73-year-old female presents with complaints of abdominal pain, weight loss, and early satiety. She states that she has been experiencing a “gnawing” pain in the mid-epigastrium. The pain started 8 months ago. She attributed it to “indigestion.” She took an over-the-counter proton pump inhibitor (PPI) and calcium carbonate, which initially improved the pain. The pain has progressively worsened, and now she is experiencing early satiety. Over the past 4 months, she has lost 25 lbs., is easily fatigued, and unable to perform daily tasks around the house. The patient has a 50 pack-year history of smoking. She denies more than the occasional alcoholic beverage. She moved to the United States 10 years ago from Japan. Family history includes her father passing away of “some type of cancer” and “ulcers” among two of her siblings. Physical exam reveals a cachectic female with tenderness to deep palpation in the mid-epigastrium, with no rebound or guarding. Laboratory findings include a hemoglobin of 8.5 g/dL (normal 12–15 g/dL) and hematocrit of 27% (36–47%) and mean corpuscular volume (MCV) of 65 μm3 (80–94 μm3). All other routine lab findings were within normal limits. A fecal occult blood test is positive.