What causes pain around the umbilicus (navel)?

Pain Around the Umbilicus: Causes and Clinical Approach

Periumbilical pain requires systematic evaluation to distinguish between benign conditions and life-threatening emergencies, with imaging (CT abdomen/pelvis with IV contrast) being the definitive diagnostic tool when clinical assessment is inconclusive. 1

Common Causes by Category

Gastrointestinal Pathology

The most frequent causes of periumbilical pain include:

• Appendicitis - Classically begins as periumbilical pain before migrating to the right lower quadrant, though this pattern may not be reliable in all patients 1
• Small bowel obstruction - A leading cause requiring urgent imaging evaluation 1
• Bowel inflammation or infarction - Can present with nonlocalized periumbilical discomfort 1
• Pancreatitis - Common cause of upper abdominal/periumbilical pain 1
• Perforated peptic ulcer - May present with periumbilical pain before developing peritonitis 1

Umbilical-Specific Pathology

Direct umbilical involvement includes:

• Umbilical hernia with incarceration/strangulation - Can contain bowel, omentum, or rarely appendix, causing pain and potential obstruction 2
• Omphalitis (umbilical infection) - Presents with erythema, edema, tenderness, and purulent discharge; can lead to periumbilical cellulitis, intra-abdominal abscesses, portal vein thrombophlebitis, peritonitis, and bowel ischemia 1, 3
• Urachal remnant infection - Can cause umbilical abscess and omphalitis in adults 3
• Umbilical dermatoses and tumors - Various benign and malignant conditions may localize to the umbilicus 4

Vascular Emergencies

Life-threatening causes that must be excluded:

• Mesenteric ischemia/bowel infarction - Can present with periumbilical pain disproportionate to physical findings 1
• Abdominal aortic aneurysm - Though pain radiating below the umbilicus is less likely cardiac in origin, vascular pathology must be considered 1

Other Significant Causes

• Diverticulitis - Common cause of abdominal pain requiring imaging 1
• Nephrolithiasis/renal colic - Can cause referred periumbilical discomfort 1
• Intra-abdominal abscess - May present with fever and nonlocalized pain 1
• Malignancy - Including lymphoma and other tumors 1

Diagnostic Approach

Clinical Assessment

Obtain focused history including: 1

• Pain characteristics: Gradual onset over minutes suggests visceral pathology; sudden "ripping" pain suggests vascular emergency 1
• Duration: Fleeting seconds unlikely serious; persistent pain requires investigation 1
• Radiation pattern: Pain radiating below the umbilicus or to hips is unlikely myocardial ischemia 1
• Associated symptoms: Fever, nausea, vomiting, changes in bowel habits, urinary symptoms 1
• Risk factors: Recent surgery, immunosuppression, pregnancy, known hernias 1

Imaging Strategy

For nonlocalized periumbilical pain with or without fever: 1

• CT abdomen/pelvis with IV contrast is the primary diagnostic modality - Provides comprehensive evaluation for appendicitis, bowel obstruction, perforation, abscesses, pancreatitis, diverticulitis, and malignancy 1
• CT without contrast is appropriate if patient cannot receive IV contrast 1
• Ultrasound may be initial modality in younger patients, pregnant patients, or when specific conditions (cholecystitis, appendicitis) are suspected 1
• MRI abdomen/pelvis can provide clinically useful information when CT is contraindicated, particularly in pregnancy 1

Special Populations

Pregnant patients: 1

• Ultrasound is the primary imaging modality
• Appendicitis is the most common surgical emergency; pain location may not follow typical patterns 1
• MRI without contrast is the next step if ultrasound is inconclusive 1

Postoperative patients: 1

• CT with IV contrast to evaluate for abscesses, anastomotic leaks, or hemorrhage 1

Neutropenic/immunocompromised patients: 1

• CT with IV contrast to evaluate for atypical infections, opportunistic pathogens, and underlying malignancy 1
• High mortality risk necessitates aggressive imaging approach 1

Critical Pitfalls to Avoid

• Do not assume benign etiology based on pain characteristics alone - One-third of ED patients with abdominal pain never receive a definitive diagnosis, underscoring diagnostic difficulty 1
• Do not delay imaging in elderly or immunocompromised patients - Laboratory tests may be normal despite serious infection 1
• Do not overlook umbilical examination - Direct inspection for erythema, discharge, masses, or hernias is essential 1, 3
• In pregnant patients, do not assume typical appendicitis presentation - Pain location is unreliable 1