In the setting of chronic liver disease, portal hypertension and its complications pose major challenges in management. Once it develops, portal hypertension is the source of potentially devastating sequelae, including life-threatening hemorrhage, infection, renal failure, and encephalopathy. Improved understanding of the pathophysiology of these conditions has led to advances in endoscopic, radiologic, medical, and surgical management. The possibility in selected cases of successful amelioration of portal hypertension and its dreaded complications by liver transplantation highlights the importance of timely and careful management of patients with decompensated cirrhosis.