ICD 10 CM S31.612 | Description & Clinical Information

ICD 10 S31.612 describes a specific medical condition characterized by a deep and irregular cut or tear in the skin of the abdominal wall located over the stomach, which penetrates the peritoneal cavity, a space within the peritoneum, without any foreign object being retained, and may or may not result in bleeding.

Official Description Of S31.612

The ICD 10 CM book defines ICD 10 code S31.612 as:

When To Use S31.612

The diagnosis describes by the ICD 10 CM S31.612 code is a laceration without a foreign body in the epigastric region of the abdominal wall that penetrates into the peritoneal cavity. This injury can result in pain and tenderness in the affected area, along with bleeding, shock, bruising, infection, injury to abdominal organs, fever, nausea with vomiting, swelling, and inflammation.

Medical providers typically diagnose this condition based on the patient’s personal history of trauma and a physical examination to assess the wound, nerves, or blood supply. The physical examination may involve palpation of the abdominal area to check for areas of tenderness, swelling, or any deformity.

Medical imaging techniques such as X-rays, CT scans, and ultrasound may also be used to determine the extent of the injury. Laboratory evaluations such as blood tests may be ordered to check for signs of infection or other complications that may have developed as a result of the injury.

In some cases, peritoneal lavage may be performed to determine the extent of damage to abdominal organs. This procedure involves inserting a needle through the abdominal wall and into the peritoneal cavity, then flushing the area with a sterile solution to identify any signs of internal bleeding or other damage.

Once a diagnosis has been made, treatment options will depend on the severity of the injury. If bleeding is present, the priority will be to stop it. This may involve administering intravenous fluids and blood products to replace lost blood volume.

Cleaning, debriding, and repairing the wound will likely also be necessary. This may involve the application of appropriate topical medication and dressing, as well as administration of antibiotics and/or tetanus prophylaxis to prevent infection.

Pain management will also be necessary, and this may involve the administration of analgesics and/or nonsteroidal anti-inflammatory drugs (NSAIDs). In severe cases, surgical repair of the injured organs may be required to prevent further complications.

Ultimately, the prognosis for this type of injury will depend on the severity of the trauma and the effectiveness of treatment. With appropriate medical care, however, most patients can fully recover from an injury of this nature and regain their previous level of function.