EUS-Guided Shunt Occlusion for Refractory Hepatic Encephalopathy: A Three-Case Series Demonstrating a Promising Alternative to BRTO and TIPS

We retrospectively analyzed three male patients (ages 41–66) with ethanol-related cirrhosis and recurrent OHE despite optimal medical therapy. All had large splenorenal or splenoportal shunts documented on CT, with significant portofugal flow on Doppler. Due to financial constraints or high MELD, liver transplantation, BRTO, and TIPS were not feasible.

Under deep sedation, an echoendoscope was positioned at the gastric cardia to visualize the splenoportal axis. The afferent feeder to the shunt was identified using Doppler, and a 19G EUS-FNA needle was used for direct puncture. Technique involved deployment of 18–20 mm coils followed by n-butyl cyanoacrylate glue injection, in single or staged sessions, depending on residual flow. Coil number ranged from 2 to 6 per patient. Post-procedure, patients were monitored for bleeding, ascites, hypoxia, and worsening decompensation. CT portography was repeated after 4–6 weeks. Clinical follow-up included MELD score, HE episodes, and functional status assessment.

Case 1 (66-year-old male): Large splenoportal shunt with recurrent HE. Single-session ETSO with two coils and 2 ml glue achieved complete obliteration. No complications. No further HE over 3 months; improved cognition reported.

Case 2 (57-year-old male, MELD 28): Large posterior gastric vein afferent shunt. Initial coil + glue session partially occluded flow. A second puncture achieved complete thrombosis. Developed mild hemoperitoneum and ascites, managed with correction of coagulopathy. Hospital stay: 20 days. After discharge, only one minor HE episode occurred at 3 weeks, and none thereafter. CT at 35 days showed complete non-opacification of shunt without thrombus extension. MELD improved to 25 at 2 months.

Case 3 (41-year-old male, MELD 13): 1.5–2 cm splenorenal shunt. Staged ETSO was required due to shunt size. Three sessions performed over 2 weeks with multiple coils and 4 ml glue. Mild post-procedure hypoxia occurred, managed conservatively. CT showed partial and progressive obliteration. No episodes of OHE in last month. Improved sensorium and liver function.

Across all cases: Technical success: 100%; Clinical control of OHE: achieved in all three; No portal vein/systemic thrombus extension; No mortality; MELD improvement in all three patients; Average follow-up: 2 months

This case series demonstrates that EUS-guided shunt occlusion is a feasible and effective therapeutic alternative for patients with recurrent HE and contraindications to TIPS, BRTO, or transplantation. The ability to directly visualize and selectively embolize the shunt afferent offers distinct procedural precision over radiologic methods. While mild complications occurred, all were manageable, and neurocognitive improvement was consistent across patients.

ETSO may represent an emerging interventional paradigm in hepatology, particularly within resource-constrained settings. A multicentric prospective study is urgently needed to establish standardized protocols, optimal coil–glue combinations, and long-term outcomes beyond encephalopathy control, including survival and portal hemodynamics.