Gallstones occur more commonly in patients with cirrhosis. The incidence increases with severity of liver disease, and the majority remain asymptomatic. When symptoms do occur, morbidity and mortality are much higher than in noncirrhotic patients. Asymptomatic gallstones in cirrhotic patients are best managed conservatively with close follow-up and surgery if symptoms occur. The management of asymptomatic gallstones found incidentally at abdominal surgery for another indication is controversial. Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis in patients with well-compensated liver disease, whereas patients with choledocholithiasis are best managed endoscopically. Symptomatic cholelithiasis in the decompensated patient remains a challenge, and these patients are best managed in specialized hepatobiliary centers. This review examines the evidence currently available on gallstones in chronic liver disease and the factors that influence its management.