- A hiatal hernia causing or aggravating ascites by compressing the hepatic veins has been rarely reported in adults. We report a patient with a known hiatal hernia who was presented with refractory as-cites. Echocardiography and CT examination demonstrated a huge hiatal hernia compressing the right atrium and the inferior vena cava. A right-sided heart catheterization demonstrated a significant pressure gradient between the inferior vena cava and the right atrium. Liver biopsy showed a nodular pattern and congestion without fibro-sis. Hernioplasty was performed and an improvement in the rate of the accumulation of ascetic fluid was observed. Three months later and during a follow-up period of 3 years, the ascites was mild and there was no need for any therapeutic paracentesis. The outcome indicates that the huge hiatal hernia, by creating hepatic venous outflow obstruction, was the underlying mechanism for ascites aggravation.