A case of dramatic portal hypertension with massive ascites and splenomegaly is described in a patient with inflammatory bowel disease receiving azathioprine therapy. Liver biopsy confirmed the subtle changes of nodular regenerative hyperplasia and the patient recovered following withdrawal of the azathioprine and commencement of spironolactone. Thrombocytopaenia is an early clue to azathioprine-induced nodular regenerative hyperplasia of the liver.