Differential Diagnosis

The patient's presentation of epigastric pain with a history of multiple similar episodes, in the context of alcoholism, guides the differential diagnosis. Here's the organized differential:

• Single most likely diagnosis

  • B. Chronic pancreatitis: This is the most likely diagnosis given the patient's history of alcoholism and recurrent episodes of epigastric pain. Chronic pancreatitis is a known complication of long-standing alcohol abuse, which can cause chronic inflammation of the pancreas leading to pain.

• Other Likely diagnoses

  • A. Biliary colic: Although the bilirubin levels are normal, biliary colic remains a possibility, especially if the patient has gallstones. The pain from biliary colic can sometimes be referred to the epigastric area.
  • C. Pyelonephritis: While the WBC count is normal, which might argue against an infectious process like pyelonephritis, it's essential to consider this diagnosis, especially if the patient has a history of urinary tract infections or other predisposing factors. However, the lack of specific symptoms like flank pain or dysuria makes this less likely.

• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)

  • Ischemic colitis: Although less likely given the presentation, ischemic colitis can cause severe abdominal pain and is a condition that requires prompt diagnosis and treatment to prevent significant morbidity and mortality.
  • Peptic ulcer disease: Not listed among the options but crucial to consider in the differential diagnosis of epigastric pain, especially in the context of alcohol use which can increase the risk of peptic ulcers.

• Rare diagnoses

  • Other rare causes of abdominal pain such as pancreatic cancer, although less likely, should be considered, especially if other diagnoses are ruled out and the patient continues to experience symptoms. However, these would be less common and typically present with additional symptoms or findings not mentioned in the scenario.