The Portosystemic Shunt Syndrome and Role of Shunt Embolization in the Management of Hepatic Encephalopathy

Purpose of Review: Portosystemic shunting (PSS) is a result of changes in hepatic hemodynamics where portal flow diverts away from the liver due to increased intrahepatic resistance from cirrhosis and is associated with hepatic encephalopathy (HE). Over time, increased PSS may directly lead to worsening liver failure because of severely decreased loss of effective portal inflow towards the liver and result in recurrent or persistent HE. This clinical scenario has been recently defined as “portosystemic shunt syndrome” and has been associated with poor clinical outcomes. Recent Findings: The presence of PSS is common in patients with cirrhosis and increased PSS size appears to correlate with recurrent or persistent HE. Recent studies have shown that patients with Model for End-Stage Liver Disease (MELD) score < 11 have demonstrated high clinical benefit in recurrent or persistent HE when treated with shunt embolization. Summary: There is a growing literature that demonstrates potential clinical benefit using PSS embolization for selected patients, particularly with MELD under 11, with recurrent or persistent HE. Further investigation into improved risk stratification in order to determine effective treatments is necessary as well as heightened detection of the portosystemic shunt syndrome in its earlier and possibly reversible stages.