How do you determine when you would treat an identified spleno-renal shunt and how?

It is important to remember that the typical reason portal hypertension develops is to try and accommodate the increased resistance across the cirrhotic liver. A spleno-renal shunt is a congenital malformation that is often noted when a patient develops portal hypertension. Prior to TIPS, these were created surgically to try and relieve portal hypertension. Keeping this in mind, closing a shunt should be considered in cases where the shunt is the likely cause of either refractory hepatic encephalopathy (HE) or evidence of venous "steal". Typically, for my practice, the shunt is closed due to patient who have either acute and abrupt episodes of acute onset HE or recalcitrant HE. When a shunt is closed, it is to be expected that portal hypert...

To add to Dr. @Dr. First Last's response, I mainly first look for these when there are cases of refractory or persistent episodes of hepatic encephalopathy. This would be the first symptom of a functionally significant SRS. If standard measures are not working for HE management, then I make sure we have a good-quality cross-sectional imaging scan to look specifically for this (to the point where I put in the radiology requisition "assess for SRS"). If present, I then chat with interventional radiology regarding the benefit and feasibility of closing an SRS. We must acknowledge that varices and ascites may worsen, and we may need to consider a TIPS in conjunction with SRS closure. The idea behind this is that the TIPS creation is more hemody...