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This review provides a comprehensive overview of treatment strategies for these cases, along with a comparative analysis of the American Association for the Study of Liver Diseases, Baveno VII, and Japanese clinical practice guidelines. Treatment approaches are classified into four domains: endoscopic therapy, interventional radiology (IVR), surgical procedures, and internal medicine\u2010based strategies. In recent years, clinical practice has shifted from traditional surgical interventions and transjugular intrahepatic portosystemic shunt (TIPS) to minimally invasive IVR techniques, such as partial splenic embolization, percutaneous transhepatic obliteration, and transileocolic vein obliteration, often combined with endoscopic methods. In Japan, where TIPS is not routinely performed due to limited availability and lack of insurance coverage, these alternative IVR procedures are more commonly utilized. Differences among regional guidelines highlight the need for adaptable treatment strategies based on local resources and institutional expertise. Effective management of refractory cases requires multidisciplinary collaboration among gastroenterologists, interventional radiologists, and surgeons. 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