Differential Diagnosis for Epigastric Abdominal Pain

The patient presents with intermittent epigastric abdominal pain radiating to the back, elevated WBC count, mild anemia, and elevated AST with normal ALT and lipase levels. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Peptic Ulcer Disease (PUD): The patient's symptoms of epigastric pain radiating to the back, along with an elevated WBC count indicating possible inflammation, and mild anemia which could be due to chronic blood loss, point towards PUD. The elevated AST could be due to a variety of reasons including medication use or mild liver dysfunction, but it does not strongly point away from PUD given the other symptoms.

• Other Likely Diagnoses

  • Cholecystitis: Although the lipase is within normal limits, which makes pancreatitis less likely, cholecystitis (inflammation of the gallbladder) could still be a consideration, especially if the patient has gallstones. The elevated WBC count supports an infectious or inflammatory process.
  • Pancreatitis: Despite the normal lipase level, pancreatitis cannot be entirely ruled out, especially if the patient has a history of alcohol use or other risk factors. Some cases of pancreatitis may have normal or only slightly elevated lipase levels, especially if the test is done late in the course of the disease.
  • Hepatitis: The elevated AST with normal ALT and bilirubin could suggest hepatitis, although the clinical presentation is not typical. Hepatitis could cause abdominal pain and elevated liver enzymes.

• Do Not Miss Diagnoses

  • Ectopic Pregnancy: Although the patient's presentation does not strongly suggest ectopic pregnancy, it is a critical diagnosis to consider in any female of childbearing age presenting with abdominal pain, due to its potential for severe morbidity and mortality. A pregnancy test should be considered.
  • Appendicitis: While the pain is epigastric and radiates to the back, atypical presentations of appendicitis can occur, especially if the appendix is retrocecal. The elevated WBC count supports a possible infectious or inflammatory process.
  • Pancreatic Cancer: Although rare in a 25-year-old, pancreatic cancer can present with abdominal pain radiating to the back and should be considered, especially if other diagnoses are ruled out and the pain persists.

• Rare Diagnoses

  • Gastric Cancer: Very rare in someone as young as 25, but could present with epigastric pain and weight loss.
  • Inflammatory Bowel Disease (IBD): Conditions like Crohn's disease or ulcerative colitis could present with abdominal pain, although they typically have other symptoms like diarrhea or weight loss.
  • Porphyria: A group of disorders that can cause severe abdominal pain, among other symptoms. The diagnosis is often challenging and requires a high index of suspicion.