Portal pneumatosis is a rare diagnostic factor, which is often associated with ischemic intestinal accidents. It has been associated with a negative prognosis for a very long time, and the presence of portal pneumatosis is usually an indication for the need to perform a laparotomy. A 68-year-old male patient with diabetes, obstructive lung disease, and a previous cerebral stroke associated with left hemiplegia presented with abdominal pain, fever and neutrophil leukocytosis. Computed tomography (CT) scan showed the presence of portal pneumatosis with signs of acute cholecystitis and remarkable gastrectasia. In consideration of the serious clinical picture, the patient first underwent esophagogastroduodenal endoscopy (EGDS), which showed ulcerative hemorrhagic gastritis. He then underwent a laparoscopic cholecystectomy. The histology results confirmed the intraoperative diagnosis of gangrenous cholecystitis. The patient was discharged on the 7th postoperative day. With the use of new diagnostic techniques, especially CT, the incidence of portal pneumatosis has increased and consequently the clinical approach of surgeons to this pathology is also changing. Indeed, when portal pneumatosis is not associated with intestinal ischemia, the therapeutic approach must be guided by the clinical condition of the patient and by the investigation of the causes of this pathology. The laparoscopic approach can be extremely useful either in the diagnosis (if this has not been achieved by noninvasive means) or in treatment, if possible, of the causes implicated by the portal pneumatosis.