Hepatic portal venous gas as an early sign of nonocclusive mesenteric ischemia in diabetic ketoacidosis.

Diabetic ketoacidosis (DKA) is a life-threatening condition requiring immediate clinical intervention, and clinicians should maintain a high index of suspicion when treating patients with diabetes or associated DKA risk factors. However, DKA complicated by nonocclusive mesenteric ischemia (NOMI) and hepatic portal venous gas (HPVG) accumulation is extremely rare, difficult to identify clinically, and prone to misdiagnosis or missed diagnosis. We report the case of a young adult male with DKA, NOMI, HPVG, septic shock, lactic acidosis, acute kidney failure, coagulation disorders, and rhabdomyolysis. No mechanical mesenteric vascular occlusion was identified; therefore, NOMI was considered to be secondary to mesenteric vasoconstriction associated with septic shock and hypovolemia. While NOMI is detected primarily among elderly individuals prone to vascular diseases, this case demonstrates the potential for NOMI among younger DKA patients. Early diagnosis, aggressive resuscitation, continuous renal replacement therapy, and administration of vasopressors and broad-spectrum antibiotics are essential for patient survival.