Barium-associated intestinal ischemia is a rare but life-threatening complication following upper gastrointestinal barium contrast examinations, with an incidence of less than 0.01%. Hepatic portal venous gas is a condition secondary to intra-abdominal lesions, such as intestinal ischemia and intestinal necrosis. When complicated by intestinal necrosis, the mortality rate of this condition can be as high as 50%-90%. Cases involving both barium-associated intestinal ischemia and hepatic portal venous gas are even rarer. We report the case of a 62-year-old male patient who underwent upper gastrointestinal barium contrast examination for evaluating potential gastrointestinal disorder. Eight hours after the procedure, he developed clinical symptoms, including abdominal pain, decreased blood pressure, and increased heart rate. Abdominal computed tomography revealed enteritis, with gas detected in the hepatic portal vein, superior mesenteric vein, and intestinal wall. After 12 h of active anti-infective treatment, the gas in the hepatic portal vein was absorbed, and the symptoms improved by the second day. The patient's condition improved on the fourth day of treatment, and follow-up at 1 month confirmed complete recovery. Barium-associated intestinal ischemia is a medical emergency characterized by rapid infection and multiorgan involvement. Hepatic portal venous gas is an important indicator of underlying intra-abdominal pathology. Early anti-infective treatment and intensive care unit monitoring are critical for favorable outcomes.