Endoscopic Shunts Embolization for Refractory Hepatic Encephalopathy

Inclusion Criteria: 1. Adults aged ≥18 years with known cirrhosis 2. MRHE; defined as ≥2 episodes of hepatic encephalopathy, HE (as documented in an outpatient office visit or during an inpatient admission) within 6 months prior to enrollment despite medical therapy with lactulose and rifaximin 3. Admission to inpatient hepatology floor at University Hospital-Newark with MRHE at the time of enrollment 4. Presence of a spontaneous portosystemic shunt; confirmed on CT/MRI at the index admission. Exclusion Criteria: 1. Severe/refractory ascites defined as ascites that does not recede after medical therapy or reoccurs shortly after fluid has been removed 2. Refractory or recurrent bleeding from esophageal varices 3. Presence of portal vein thrombosis with complete occlusion 4. Hepatocellular carcinoma beyond Milan criteria or other advanced malignancy with limited life expectancy (\<6 months) 5. Platelet count of less than 35,000 and/or INR of more than 2 which cannot be corrected for the EUS guided embolization procedure. 6. Hepatic venous occlusion, or right heart failure as the etiology of cirrhosis.