Portal hypertension is a frequent consequence of liver disease, especially alcoholic cirrhosis. Unabated elevations in portal pressure may presage an esophageal variceal hemorrhage. Propranolol or isosorbide therapy is effective in the prophylaxis of variceal bleeding. In patients with acute variceal hemorrhage, endoscopic sclerotherapy or ligation is the best initial intervention. Stapled esophageal transection is often effective when endoscopic management fails. Surgical shunts have a lower associated mortality rate when they are performed electively and involve partial shunting of hepatic blood flow. Transjugular intrahepatic portosystemic shunts are indicated as a salvage procedure or as a bridge to liver transplantation. Ultimately, liver transplantation offers the best survival rate.