CASE A 73 year old female had been diagnosed as primary biliary cirrhosis and Sjögren's syndrome since the age of 50. With persisting hyperammonemia, the patient was admitted on several occasions for the management of hepatic encephalopathy. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the abdomen showed varices in the splenic hilar region and a splenorenal shunt. A balloon-occluded retrograde transvenous obliteration (B-RTO) using 5% ethanolamine oleate plus iopamidol (EOI) was performed for treatment of recurrent hepatic encephalopathy. Celiac and superior mesenteric angiograms prior to B-RTO demonstrated a hepatofugal portal circulation through the splenic varices, splenorenal shunt, left renal vein and inferior vena cava. Immediately following the B-RTO, the portal circulation became restored to a hepatopetal blood flow and no visualization of the splenic varices and splenorenal shunt was verified. On day 2 post-B-RTO, blood NH3 level was noted to have decreased from 134 to 61 μg/dL, indicating an improvement of hyperammonemia. The liver parenchymal blood flow using the dynamic CT time-concentration curve showed a decrease in hepatic artery blood flow and a marked increase in portal flow following the B-RTO. The patient has since been free from any signs of hepatic encephalopathy due to hyperammonemia for over 5 years following the B-RTO. CONCLUSIONS B-RTO may be considered useful for the treatment of severe recurrent hepatic encephalopathy due to the collateral shunt in portal hypertension.