R10.816 Epigastric abdominal tenderness

ICD10CM code

#### Name of the Condition
- Epigastric Abdominal Tenderness
- ICD Code: R10.816

#### Summary
Epigastric abdominal tenderness refers to discomfort or pain felt in the upper central region of the abdomen, often described as tenderness upon touching or pressing the area.

#### Causes
This condition can arise from various causes including gastritis, peptic ulcers, pancreatitis, or even referred pain from issues in the heart. Overeating, stress, and certain medications may also contribute.

#### Risk Factors
- History of gastrointestinal diseases
- Use of NSAIDs or corticosteroids
- Excessive alcohol consumption
- Smoking
- High stress levels

#### Symptoms
Patients may experience:
- Pain or discomfort in the upper abdomen
- Nausea or vomiting
- Bloating
- Loss of appetite
- Heartburn

#### Diagnosis
Diagnosing involves:
- Physical examination focusing on the abdominal area
- Blood tests to rule out infections
- Imaging tests like an ultrasound or CT scan
- Endoscopy to inspect the stomach lining

#### Treatment Options
- Medications: Antacids, proton pump inhibitors, or H2 blockers to reduce stomach acid.
- Lifestyle modifications: Dietary adjustments and stress management.
- In severe cases, surgery may be required to treat underlying conditions like ulcers.

#### Prognosis and Follow-Up
The prognosis depends on the underlying cause. With proper treatment and lifestyle adjustments, symptoms can significantly improve. Regular follow-ups are essential to monitor the condition and prevent recurrence.

#### Complications
If untreated, possible complications include:
- Severe gastrointestinal bleeding
- Progressive ulceration
- Dehydration from persistent vomiting

#### Lifestyle & Prevention
- Eating a balanced diet and avoiding spicy or acidic foods
- Reducing alcohol and caffeine intake
- Managing stress through relaxation techniques
- Regular physical exercise

#### When to Seek Professional Help
Seek immediate medical attention if you experience severe abdominal pain, vomiting blood, or black, tarry stools, as these can indicate serious complications.

#### Additional Resources
- American College of Gastroenterology: [gi.org](https://gi.org)
- National Institute for Diabetes and Digestive and Kidney Diseases: [niddk.nih.gov](https://www.niddk.nih.gov)

#### Tips for Medical Coders
- Ensure accurate documentation of the patient's symptoms and any underlying causes.
- Be careful not to confuse with non-specific abdominal pain (R10.9).
- Verify any associated diagnoses for comprehensive coding.

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