A 69 year old woman developed intractable episodic hepatic encephalopathy 12 years after an end-to-side portacaval shunt for variceal haemorrhage. Medical management was ineffective in preventing repeated episodes of encephalopathy and caused incapacitating faecal incontinence. A loop ileostomy was created with minimal morbidity and was effective in preventing further episodes of encephalopathy over a follow-up period of 33 months. The patient returned to a normal diet and was able to be discharged home from institutional care. Loop ileostomy is an alternative in the management of patients with hepatic encephalopathy who are poorly responsive to, and/or intolerant of, medical therapy following portasystemic shunt surgery.