Differential Diagnosis for Recurrent Severe Abdominal Pain

The patient's symptoms of recurrent severe abdominal pain, exacerbated by alcohol consumption or eating, and relieved by leaning forward, along with fatty, greasy, and oily stools and weight loss, suggest a condition affecting the pancreas. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Chronic Pancreatitis: This condition is characterized by recurrent episodes of pancreatitis leading to chronic inflammation and damage to the pancreas. The pain is typically severe, recurrent, and often radiates to the back. It can be exacerbated by alcohol consumption and eating, and leaning forward may provide relief. The presence of steatorrhea (fatty stools) and weight loss due to malabsorption of fats and other nutrients further supports this diagnosis.

• Other Likely Diagnoses

  • Peptic Ulcer Disease: While peptic ulcers can cause severe abdominal pain, the pain is usually more localized to the epigastric region and can be relieved by eating or taking antacids. However, some patients may experience pain that worsens with eating, and the presence of fatty stools could be due to other associated conditions.
  • Gallbladder Disease: Gallstones or cholecystitis can cause severe abdominal pain, especially after eating fatty foods. However, the pain is typically more localized to the right upper quadrant, and steatorrhea is not a common symptom unless there's a significant impact on pancreatic function.

• Do Not Miss Diagnoses

  • Pancreatic Cancer: Although less likely given the patient's age and the nature of the pain, pancreatic cancer can present with similar symptoms, including weight loss, steatorrhea, and abdominal pain. It's crucial to rule out this diagnosis due to its high mortality rate if left untreated.
  • Intestinal Obstruction: While less likely, an intestinal obstruction could cause severe abdominal pain and vomiting. However, the presence of steatorrhea and the specific pattern of pain relief by leaning forward are not typical for obstruction.

• Rare Diagnoses

  • Cystic Fibrosis: Although typically diagnosed in childhood, some cases of cystic fibrosis may not be diagnosed until adulthood. It can cause pancreatic insufficiency leading to steatorrhea and malabsorption, along with recurrent abdominal pain.
  • Shwachman-Diamond Syndrome: A rare genetic disorder that affects the pancreas, bone marrow, and skeleton, leading to pancreatic insufficiency and could present with similar gastrointestinal symptoms.

Each of these diagnoses should be considered and evaluated based on the patient's full clinical presentation, laboratory findings, and imaging studies to determine the most appropriate diagnosis and treatment plan.