INTRODUCTION: Portal venous gas is a rare radiological finding that demonstrates the accumulation of gas in the portal vein and its branches. It is associated with multiple pathological conditions some of which have grave prognosis and need immediate intervention. We report a case in which extensive gas was found within the hepatic portal venous and mesenteric vessels in a patient with gastric distention secondary to a bezoar. CASE DESCRIPTION/METHODS: The patient was a 53 year old male with a history of schizophrenia, maintained on psychiatric medications, who presented with complaints of vomiting and abdominal pain after binging hot dogs. Patient was found to be hypotensive, tachycardia and anemic. There was no blood noted on the rectal exam but NGT lavage produced large amounts of coffee grounds. CT abdomen displayed a distended stomach, extensive portal venous air, foci of air in multiple mesenteric vessels with dilated small bowel loops (C). Patient underwent a diagnostic laparoscopy which showed viable bowel without ischemia or incarceration. Subsequent EGD performed for hematemesis showed an ulcerating mass lesion starting in the cardia and extending into the gastric fundus (A). Biopsy revealed squamous epithelium with food particles and without malignant cells. Of note, the patient had an EGD two months prior and no mass was noted. Patient symptoms improved with NGT decompression and metoclopramide. Repeat CT showed complete resolution of previous findings (D) while repeat EGD revealed no mass lesion. With gastric distention and motility improvement all of the patients concerning findings had resolved. DISCUSSION: It has been postulated that disruption in mucosal integrity, intraluminal pressure and intestinal microflora contribute to the pathogenesis of hepatic venous gas. It is most commonly associated with bowel necrosis and very few case reports exist of a bezoar causing such findings. Bezoars can cause gastrointestinal complications like bleeding, gastric outlet obstruction or perforation. Our patient was on psychiatric medications which is known to cause slowing of gastric motility thus leading to the development of the gastric bezoar and gastric dilation. We believe that this resulted in an increase in intra-luminal pressure thus leading to the development of hepatic portal venous and mesenteric gas. This case illustrates not only how a bezoar can lead to bleeding and diffuse portal venous air but how history and prior records can help avoid unnecessary work up.Figure 1.: Ulcerating mass lesion starting in the cardia and extending into the gastric fundus.Figure 2.: Extensive portal venous air, foci of air in multiple mesenteric vessels with dilated small bowel loops.Figure 3.: Complete resolution of air in the portal and mesenteric vessels after disappearance of mass in the cardia.