To assess the incidence, pathogenesis, and associated morbidity and mortality of hyperbilirubinemia following the distal splenorenal shunt, hepatic hemodynamics, liver function, and clinical course were evaluated before and after this procedure in 78 cirrhotic patients. Individuals with a peak postoperative bilirubin level greater than 5 mg/dL had a higher preoperative bilirubin concentration, worse Child's score, longer hospital stay, and higher mortality than patients with a peak postoperative bilirubin level less than 5 mg/dL. Mean preoperative and postoperative hepatic portal perfusion and sinusoidal pressure were similar in both groups. When only patients with minimally elevated preoperative bilirubin levels (less than 2 mg/dL) were analyzed, 83% of individuals who developed postoperative hyperbilirubinemia (level, greater than 5 mg/dL) had a major alteration in hepatic hemodynamics as manifested by either complete portal vein thrombosis or a marked change in sinusoidal pressure (greater than 4 mm Hg). Although preoperative hepatic functional reserve is the major determinant of postoperative bilirubin concentration, alterations in hepatic hemodynamics secondary to the distal splenorenal shunt may also play a role.