Background: Cases of Hepatic portal venous gas (HPVG) have been associated with high mortality rates and frequently require emergency exploratory laparotomy. However, the widespread utilization of computed tomography (CT) scans has revealed that HPVG is often connected to benign conditions, as demonstrated by numerous studies. Given the intricate nature of the underlying causes of HPVG, there remains a lack of consensus regarding the necessity of emergency surgical exploration for patients with HPVG. Case Report: An octogenarian female patient was admitted to the emergency department due to abdominal pain, accompanied by symptoms of nausea and vomiting. A CT scan of the abdomen and pelvis revealed a significant presence of radiolucency in the peripheral branching of the liver, indicating the existence of portal venous gas. Subsequently, the patient was transferred to the Emergency Intensive Care Unit for further management. Colonoscopy of the patient reveals features consistent with ischemic colitis, characterized by mucosal congestion, edema, erosion, ulcers, with some ulcers covered by pseudomembranes. After undergoing a series of conservative treatments, the patient’s condition improved, as confirmed by a follow-up CT scan of the abdomen and pelvis conducted 8 days later, which showed complete absorption of the gas. Consequently, the patient was discharged from the hospital. Conclusions: The management of HPVG should take into account the pathophysiology and clinical manifestation, and should be tailored towards addressing the root cause. The selection of surgical or conservative intervention should be guided by the underlying etiology, while the prognosis and outcome of HPVG are contingent upon the underlying cause.