Differential Diagnosis for Severe Epigastric Pain in an Alcoholic Patient

• Single most likely diagnosis:
  • Acute pancreatitis: This is the most likely diagnosis given the patient's history of alcoholism and presentation with severe epigastric pain. Alcohol is a common cause of acute pancreatitis, and the symptoms align well with this condition.
• Other Likely diagnoses:
  • Acid peptic disease: Although the patient's labs and vitals are normal, acid peptic disease (including gastritis or peptic ulcer disease) could still be a consideration, especially in an alcoholic patient who may have increased gastric acid production or mucosal damage.
  • Acute cholecystitis: While less directly related to alcoholism than pancreatitis, acute cholecystitis (inflammation of the gallbladder) can cause severe epigastric pain and should be considered, especially if the patient has a history of gallstones.
• Do Not Miss diagnoses:
  • Perforated duodenal ulcer: Although less common, a perforated duodenal ulcer is a medical emergency that requires immediate surgical intervention. The patient's normal labs and vitals do not rule out this condition, as it can present with severe pain out of proportion to initial findings.
• Rare diagnoses:
  • Other rare conditions such as a gastric volvulus, splenic infarct, or even a rare form of gastritis not typically associated with alcohol could be considered, but these would be less likely given the information provided.

It's crucial to approach this patient with a thorough diagnostic workup, including imaging studies (like abdominal ultrasound or CT scan) and possibly endoscopy, to determine the exact cause of the severe epigastric pain.