A 50-year-old male who has not seen a medical provider in greater than 10 years presents to the primary care office with an approximately 6 month history of pain in his mid upper abdomen. He has a longstanding history of tobacco use and has had some increased stressors over the past few months. He describes the pain as “gnawing” and "persistent". He states the pain initially improves after eating a meal however several hours later it worsens again. He usually uses over-the-counter NSAIDs though feels this has provided no alleviation over the past few months. Vitals are all stable with the exception of some mild hypertension. On exam, he is noted to have tenderness in the epigastrium without rebound or guarding. There is no Murphy’s sign. He is not jaundiced. There is no fluid wave or pulsatile mass noted. No additional abnormalities are found. What is the most likely etiology of the patient’s symptoms?
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