A 47-year-old man was presented to our hospital with nausea , vomting ,malaise , generalized weakness , fatigue and acute abdominal pain . past hx: polyuria , polydipsia and weight loss for two month before .-ev S&S no fever, no diarrhea normal pulse . Physical examination : cvs: s1 s2 + 0, chest: clear no added sound , abdomen: diffuse abdominal pain and tender abdomen , extremities: no lower limb edema , ENT: normal ,orofacial : edema, erythema , tenderness, halitosis . Hx of bleeding during. Brush and tooth loss(E. & N. 2011).