Portal hypertension resulting from cirrhosis was one of the biggest challenges faced by general surgeons up until the past two decades. The management of portal hypertensive variceal hemorrhage has undergone dramatic changes during this period. Endoscopic variceal ligation and transjugular intrahepatic portosystemic shunts are currently used with great success. The degree of liver dysfunction remains the most important determinant of outcome in these patients. Patients with cirrhosis who have good liver function and recurrent variceal bleed remain candidates for shunt surgery. However, the need for surgical intervention has become a rarity. The success of liver transplantation has ensured that portal hypertension is cured permanently and one does not often see the critically ill and decompensated patient with cirrhosis on the surgical service. A review of the current treatment options in this very ill patient population is the primary focus of this article.