What could be causing a burning sensation around the navel in a patient?

Burning Sensation Around Navel: Diagnostic Approach and Management

Start empirical high-dose proton pump inhibitor therapy with omeprazole 20-40 mg once daily before meals for 4-8 weeks while simultaneously testing for H. pylori using breath or stool testing, as periumbilical burning most likely represents functional dyspepsia or peptic ulcer disease. 1

Immediate Assessment Required

Obtain an ECG within 10 minutes to exclude myocardial infarction, which can present atypically with isolated epigastric or periumbilical pain, especially in women, diabetics, and elderly patients, with mortality rates of 10-20% if missed. 1 Measure serial cardiac troponins at 0 and 6 hours to definitively exclude acute coronary syndrome. 1

Check vital signs immediately for:

• Tachycardia ≥110 bpm - the most sensitive early warning sign of surgical complications 2
• Fever ≥38°C - predicts perforation or sepsis with high specificity 3
• Hypotension - suggests distributive shock or serious complications 3

The combination of fever, tachycardia, and tachypnea predicts serious complications including anastomotic leak, perforation, or sepsis. 2

Critical Red Flags Requiring Urgent Imaging

Severe pain out of proportion to physical examination findings should raise immediate suspicion for acute mesenteric ischemia. 2 This is a critical pitfall - the absence of peritonitis on examination does not exclude bowel ischemia. 2

Order CT abdomen and pelvis with IV contrast immediately if any of the following are present: 3, 2

• Fever with abdominal pain
• Severe or worsening pain
• Age >55 years with new-onset symptoms
• Tachycardia or hemodynamic instability
• Concern for perforation, abscess, or ischemia

CT with IV contrast is the optimal initial imaging choice for acute nonlocalized abdominal pain, particularly when fever is present or serious pathology is suspected. 3, 2

Essential Laboratory Testing

Beta-hCG testing is mandatory in all women of reproductive age before any imaging. 2

Order baseline laboratory tests including: 2

• Complete blood count to evaluate for leukocytosis or anemia
• Serum electrolytes and glucose
• Liver and renal function tests
• C-reactive protein (superior sensitivity and specificity compared to white blood cell count for ruling in surgical disease) 2
• Serum lactate if any concern for ischemic process 2

Test for H. pylori using breath or stool testing (higher specificity than serology) as part of the "test and treat" strategy, which ranks first in reducing symptoms at 12 months (RR 0.89; 95% CI 0.78-1.0). 1

Most Likely Diagnosis: Functional Dyspepsia

Periumbilical burning pain typically represents functional dyspepsia, which is caused by issues with the two-way communication between the upper gut and the brain. 3 Problems with the nerves supplying the stomach and duodenum may make them more sensitive to normal function. 3

H. pylori infection alters gastric function and contributes to dyspeptic symptoms, making testing essential in all patients with dyspepsia. 3, 4

Treatment Algorithm

First-Line Therapy

Initiate omeprazole 20-40 mg once daily before meals for 4-8 weeks, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers. 1

If H. pylori Positive

Treat with triple therapy: omeprazole 20 mg + Amoxicillin 1000 mg + Clarithromycin 500 mg, all twice daily for 10 days. 1 All patients with functional dyspepsia should receive antibiotic treatment if H. pylori testing is positive to see if symptoms improve. 3

If No Response After 2-4 Weeks

Switch drug class or increase PPI dosing. 1

Dietary Considerations

Consider a 2-week dietary elimination trial to reduce high-sulfur foods, as prolonged fermentation of sulfur-containing foods produces hydrogen sulfide gas. 4 Carbohydrate malabsorption (lactose intolerance, fructose intolerance, sucrase deficiency) can contribute to symptoms. 4

Regular exercise and lifestyle changes, like avoiding certain foods that may trigger symptoms, will be helpful for some patients. 3

When to Perform Endoscopy

Age-based and symptom-based criteria for endoscopy include: 1

• Age ≥55 years with treatment-resistant dyspepsia
• Age ≥40 years from high-risk area or with family history of gastroesophageal malignancy
• Any age with alarm features: weight loss, anemia, dysphagia, persistent vomiting, or hematemesis

Reassess at 4 weeks, and if symptoms persist despite adequate PPI trial and negative H. pylori, consider endoscopy regardless of age. 1

Special Population Considerations

Elderly patients have a higher likelihood of malignancy, diverticulitis, and vascular causes. 2 In elderly patients with fever and abdominal pain, many laboratory tests may be normal despite serious infection. 3, 2

Common Pitfalls to Avoid

• Normal lactate does not exclude internal herniation or early ischemia. 2
• Normal laboratory tests in elderly patients do not exclude serious infection. 3, 2
• Restricting diet too much could lead to malnutrition or abnormal eating habits - there is no evidence for any specialized diets for treating functional dyspepsia. 3
• Review recent medication changes, as NSAIDs and opioids can alter gut motility and contribute to dyspepsia. 4