Andrew is a 69-year-old retired public servant who presents with vague epigastric and periumbilical burning pain that has kept him awake at night for the past few weeks.

There is no obvious relationship to meals, and symptoms are minimal during the day. OTC esomeprazole has provided short-term relief and improved sleep. Andrew reports no recent weight loss, nausea or change of bowel habits. He is usually well, has no significant medical history and takes no medications. He is a long-term ex-smoker and drinks socially, with two alcohol-free days a week.

A colonoscopy eight years ago found a tubular adenoma; however, Andrew did not attend the recommended follow-up colonoscopy at five years. He had a negative FOBT six months previously. His family history includes a pancreatic problem in his paternal grandfather, although the exact diagnosis is unknown.

On examination, Andrew’s appearance suggests good health. He weighs 81kg, his BMI is 26kg/m2 and his vital signs are within normal limits. There are no signs of anaemia or jaundice. He has minor tenderness above the umbilicus and no abdominal masses.