Transjugular intrahepatic portosystemic shunt and non-selective beta-blockers act as friends or foe in decompensated cirrhosis: A comparative review

Abstract

The management of portal hypertension and its complications, such as variceal bleeding, in patients with cirrhosis often involves the use of nonselective beta-blockers (NSBBs) and a transjugular intrahepatic portosystemic shunt (TIPS). Both treatment modalities have demonstrated efficacy; however, each presents distinct challenges and benefits. NSBBs, including propranolol, nadolol, and carvedilol, effectively reduce portal pressure, but are associated with side effects such as bradycardia, hypotension, fatigue, and respiratory issues. Additionally, NSBBs can exacerbate conditions such as refractory ascites, hepatorenal syndrome, and hepatic encephalopathy. In contrast, TIPS effectively reduces the incidence of variceal rebleeding, controlling refractory ascites. However, it is associated with a significant risk of hepatic encephalopathy, shunt dysfunction, and procedure-related complications including bleeding and infection. The high cost of TIPS, along with the need for regular follow-up and potential re-intervention, poses additional challenges. Furthermore, patient selection for TIPS is critical, as inappropriate candidates may experience suboptimal outcomes. Future studies comparing NSBBs and TIPS should focus on refining the patient selection criteria, enhancing procedural techniques, optimising combination therapies, and conducting long-term outcome studies. Personalised treatment approaches, cost-effectiveness analyses, and improved patient education and support are essential for maximising the use of these therapies.

Keywords: Transjugular intrahepatic portosystemic shunt; Liver cirrhosis; Variceal bleeding; Nonselective beta-blockers; Portal hypertension

Core Tip: The management of portal hypertension in decompensated cirrhosis often involves nonselective beta-blockers (NSBBs) and a transjugular intrahepatic portosystemic shunt (TIPS). Although NSBBs effectively reduce portal pressure and prevent variceal bleeding, they can cause significant side effects, negatively impacting adherence. Conversely, TIPS provides rapid relief from variceal bleeding but carries risks such as hepatic encephalopathy and other complications. However, both treatments require careful patient selection and monitoring. Future strategies should focus on optimising patient management, enhancing procedural techniques, and integrating personalised approaches to improve outcomes in patients with cirrhosis.