I86.4

Gastric varices

Gastric varices are dilated, tortuous submucosal veins located within the stomach wall that develop primarily as a compensatory response to increased pressure in the portal venous system, a condition known as portal hypertension. While less common than esophageal varices, gastric varices are associated with a significantly higher risk of massive, life-threatening hemorrhage and present unique therapeutic challenges due to their deep location and high-volume blood flow. These varices are anatomically and hemodynamically distinct from esophageal varices and are typically classified using the Sarin classification system into Gastroesophageal Varices (GOV type 1 and 2) and Isolated Gastric Varices (IGV type 1 and 2). IGV1, found in the gastric fundus, are particularly dangerous as they can rupture even at lower portal pressures compared to esophageal varices. Management is complex and often requires specialized interventions such as endoscopic cyanoacrylate 'glue' injection, Transjugular Intrahepatic Portosystemic Shunt (TIPS), or Balloon-occluded Retrograde Transvenous Obliteration (BRTO).

Clinical Symptoms

Hematemesis (vomiting of bright red blood or coffee-ground material)
Melena (passage of black, tarry, foul-smelling stools)
Hematochezia (passage of fresh blood per rectum, indicating massive hemorrhage)
Orthostatic hypotension (lightheadedness or dizziness upon standing)
Tachycardia (rapid resting heart rate)
Syncope (fainting due to acute blood loss)
Pallor and chronic fatigue (secondary to occult gastrointestinal bleeding)
Abdominal distension (ascites) from underlying liver disease
Mental status changes (hepatic encephalopathy) triggered by gastrointestinal bleeding
Splenomegaly (enlarged spleen often palpable on physical exam)

Common Causes

Portal hypertension (the primary driver in the majority of cases)
Liver cirrhosis (secondary to chronic alcohol use, Viral Hepatitis B or C, or Non-alcoholic steatohepatitis)
Splenic vein thrombosis (commonly associated with chronic pancreatitis, pancreatic pseudocysts, or pancreatic malignancy)
Portal vein thrombosis (caused by hypercoagulable states, abdominal infections, or malignancies)
Budd-Chiari syndrome (obstruction of hepatic venous outflow)
Schistosomiasis (parasitic infection leading to periportal fibrosis)
Arteriovenous malformations (rarely, causing localized high-pressure venous states)
Sarcoidosis (granulomatous liver involvement leading to portal hypertension)

Documentation & Coding Tips

Document the underlying cause of portal hypertension to ensure the highest level of specificity and accurate risk adjustment.

Example: Patient with known cirrhosis due to chronic Hepatitis C (K74.60) presents with gastric varices (I86.4). Evaluation reveals portal hypertension (K76.6) as the primary driver. Current status is stable with no signs of active hemorrhage.

Billing Focus: Documentation must specify the underlying etiology, such as cirrhosis or splenic vein thrombosis, to link the varices to a primary condition.

Specify the presence or absence of hemorrhage clearly within the diagnosis statement.

Example: Acute upper gastrointestinal hemorrhage (K92.2) from gastric varices (I86.4) in a patient with alcoholic cirrhosis with ascites (K70.31). Successful endoscopic cyanoacrylate injection performed.

Billing Focus: Bleeding status determines the primary ICD-10 code selection in many clinical settings and influences the complexity of the medical decision-making.

Describe the Sarin classification or anatomical location of the varices to support procedural necessity.

Example: Esophagogastroduodenoscopy (EGD) identified IGV1 (Isolated Gastric Varices type 1) located in the fundus. These are large, high-risk gastric varices (I86.4) measuring over 5mm.

Billing Focus: Detailed anatomical site documentation supports the medical necessity for specific interventions like BRTO (Balloon-occluded Retrograde Transvenous Obliteration).

Include associated complications such as portal hypertensive gastropathy or hypersplenism.

Example: Gastric varices (I86.4) identified during screening for a patient with non-alcoholic steatohepatitis (K75.81) and portal hypertensive gastropathy (K76.6). Splenomegaly (R16.1) noted on imaging.

Billing Focus: Documenting co-occurring conditions like portal hypertensive gastropathy ensures the full clinical picture is captured for coding and billing accuracy.

Differentiate between gastric varices and esophageal varices, or note if both are present.

Example: EGD confirms both esophageal varices (I85.00) and gastric varices (I86.4) extending along the lesser curvature (GOV1). No active bleeding noted during this surveillance encounter.

Billing Focus: Codes for both esophageal and gastric varices should be reported when both are documented to reflect the total procedural and diagnostic complexity.

Relevant CPT Codes

43244 - Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal and/or gastric varices
Direct treatment for gastric varices that are at high risk of bleeding or currently bleeding.
43243 - Esophagogastroduodenoscopy, flexible, transoral; with injection sclerosis of esophageal and/or gastric varices
Often the preferred endoscopic treatment for fundal gastric varices where banding is difficult.
37244 - Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation
Applicable for BRTO (Balloon-occluded Retrograde Transvenous Obliteration) procedures used specifically for gastric varices.
43235 - Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
The standard procedure for identifying and classifying gastric varices.
99214 - Office or other outpatient visit for the evaluation and management of an established patient, which requires a moderate level of medical decision making
Appropriate for managing patients with chronic liver disease and stable gastric varices involving multiple treatment options.
99215 - Office or other outpatient visit for the evaluation and management of an established patient, which requires a high level of medical decision making
Required when managing decompensated cirrhosis with gastric varices and coordinating complex interventions like TIPS or BRTO.
99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires a low level of medical decision making
Used for stable patients with known gastric varices requiring basic monitoring and education.
37182 - Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS)
A definitive treatment to reduce the pressure causing gastric varices when other methods fail.
91035 - Esophagus, gastroesophageal reflux test; with mucosal monitoring; capsule placement, attachment, and interpretation
Occasionally used to differentiate variceal symptoms from severe GERD in cirrhotic patients.
76700 - Ultrasound, abdominal, real time with image documentation; complete
Non-invasive imaging to assess the cause of gastric varices (e.g., cirrhosis, thrombosis).