Not All That Glows Is Ischaemia: Extensive Hepatic and Mesenteric Venous Gas From Sigmoid Diverticulitis

Hepatic portal venous gas (HPVG) is a rare radiological finding most commonly associated with bowel ischaemia and high mortality. However, it can also occur in benign conditions such as diverticulitis, where the clinical course may be less severe. Management decisions must balance the alarming imaging appearance with the patient's clinical stability. We present the case of a 47-year-old male patient with underlying diverticular disease who developed extensive HPVG and mesenteric venous gas secondary to sigmoid diverticulitis. Despite the dramatic radiological findings, he remained haemodynamically stable with no signs of peritonism. Blood cultures grew Pseudomonas aeruginosa and Escherichia coli, suggesting a gas-forming infective source. He was managed conservatively with intravenous antibiotics and close monitoring. Repeat imaging showed a significant reduction in portal venous gas, and the patient made a full recovery without requiring surgery. He was discharged on day 9 with outpatient follow-up for elective sigmoid colectomy. This case highlights that HPVG, while often considered a surgical emergency, may be managed non-operatively in selected patients with diverticulitis who are clinically stable. Multidisciplinary evaluation and careful correlation between imaging and clinical findings are essential in guiding appropriate management.