What could be causing fluttering sensations throughout the abdomen and under the right breast in a patient without pain or palpitations?

Fluttering Sensations in Abdomen and Under Right Breast

The fluttering sensations throughout the abdomen and under the right breast without pain or palpitations are most likely normal vascular pulsations from the abdominal aorta or internal mammary artery, though diaphragmatic flutter should be considered if the movements are visible or rhythmic. 1

Initial Diagnostic Approach

The key distinction is whether this represents normal vascular pulsations versus a neuromuscular phenomenon:

• Determine if the sensation is visible, palpable, or audible to differentiate between benign vascular pulsations and potential pathology 1
• Normal arterial pulsations from the abdominal aorta or internal mammary artery branches commonly cause benign pulsating sensations in thin individuals 1
• Auscultate over the area for a continuous murmur, which if present and resolves with compression, indicates a benign mammary souffle 1

Diaphragmatic Flutter Consideration

If the abdominal movements are visible and rhythmic, diaphragmatic flutter becomes a more likely diagnosis:

• Diaphragmatic flutter presents with involuntary, irregular, hyperkinetic abdominal wall movements that can occur throughout the abdomen 2
• The condition involves rapid rhythmic involuntary contractions of the diaphragm, typically at frequencies of 0.5-8.0 Hz (classic form) or 9-15 Hz (high-frequency variant) 3
• High-frequency diaphragmatic flutter can present with symptoms like belching, hiccups, or retching rather than the classic dyspnea and pain 3
• Diagnosis requires diaphragmatic fluoroscopy or electromyography showing repetitive high-frequency discharges 2, 3

When to Pursue Imaging for Breast Area Symptoms

The sensation under the right breast requires limited evaluation given the absence of pain:

• Focal breast symptoms without pain are rarely associated with malignancy (0-3% cancer risk when pain is the only symptom) 4, 1
• If a palpable cord-like structure develops with pain, consider Mondor disease (thrombosed thoracoepigastric vein) 4, 1
• Age-appropriate imaging is only indicated if focal pain develops or a mass is palpable: ultrasound alone for women under 30 years, or mammography with ultrasound for women 30 years and older 1

Management Algorithm

For presumed normal vascular pulsations:

• Provide reassurance that these sensations represent normal vascular anatomy 1
• No imaging or treatment is required if examination is benign 1

If diaphragmatic flutter is suspected (visible rhythmic abdominal movements):

• Obtain diaphragmatic fluoroscopy or electromyography to confirm diagnosis 2, 3
• Trial carbamazepine 200-400 mg three times daily, which has shown effectiveness in eliminating or greatly improving high-frequency diaphragmatic flutter 3
• Noninvasive ventilatory support can instantaneously halt flutter episodes by resting the diaphragm 5

Critical Pitfalls to Avoid

• Do not dismiss focal breast symptoms without proper evaluation, as some cancers (particularly invasive lobular carcinoma and anaplastic carcinoma) can present with unusual symptoms 6, 1
• Do not assume cardiac origin without appropriate cardiac evaluation if pulsations are concerning 2
• Do not order imaging for nonfocal or cyclical breast sensations, as this increases subsequent clinical visits without improving outcomes 4