Acta Clin Croat, Vol. 52, No. 3, 2013 369 Acta Clin Croat 2013; 52:369-373 Case Report DIFFERENTIAL DIAGNOSIS AND CLINICAL RELEVANCE OF PNEUMOBILIA OR PORTAL VEIN GAS ON ABDOMINAL X-RAY Zoran Rajković 1 , Dino Papeš 1 , Silvio Altarac 1 and Nuhi Arslani 2 1 Department of Surgery, Zabok General Hospital, Zabok, Croatia; 2 Department of Surgery, Maribor University Clinical Center, Maribor, Slovenia SUMMARY – he purpose of the article is to present the diferential diagnostic criteria between pneumobilia (air in the biliary system) and portal vein gas on abdominal x-ray. Diferential diagnosis is essential because of its inluence on patient management. Two patients are presented, one with pneumobilia and the other with portal vein gas on abdominal x-ray, with review of the relevant lite- rature. Pneumobilia is often iatrogenic and even in cases of cholecystitis it is never a sole indication for emergency surgery. Patients with pneumobilia on abdominal x-ray can always be investigated further. On the other hand, the presence of air in portal vein is in most cases a sign of acute mesen- teric ischemia. In adults with abdominal pain indicating intestinal ischemia (pain that is ‘out of pro- portion’ to clinical abdominal examination indings), it is an indication for emergency exploratory laparotomy. It is vital to act early when intestinal ischemia is suspected. Key words: Pneumobilia; Portal vein – radiography; Portal vein – pathology; Embolism, air – radio- graphy; Intestinal ischemia; Radiography, abdominal Correspondence to: Dino Papeš, MD, Department of Surgery, Zabok General Hospital, Bračak 8, HR-49210 Zabok, Croatia E-mail: dinopapes@gmail.com Received April 4, 2012, accepted February 1, 2013 Introduction Pneumobilia and portal vein gas can be similar on abdominal x-ray but diferential diagnosis is very important because of its inluence on patient manage- ment. We present two patients: one that was found to have pneumobilia due to bilioenteric istula, and an- other one that had portal vein gas associated with massive embolism of celiac axis and superior mesen- teric artery. Case 1 A 65-year-old female patient presented with dif- fuse abdominal tenderness, vomiting, and fever up to 39 °C, which lasted for three days. She had vomited up to ive times a day. Her last stool was 5 days before. On physical examination, she was dehydrated and the abdomen was soft, distended and difusely tender, without guarding. he rest of her history was unre- markable. Besides occasional analgesics, she did not take any medication. Laboratory tests showed white blood cell count (WBC) 14000/mL and C-reactive protein (CRP) 25; basic metabolic panel, red blood cell count (RBC), hemoglobin, hematocrit, amylase and lipase were within the normal range. Plain ab- dominal x-ray showed pneumobilia (Fig. 1). Upper gastrointestinal (GI) series showed communication between the duodenum and the gallbladder that was illed with air, and contrast marking the biliary tree (Fig. 2). Computed tomography (CT) scan showed a bilioenteric istula between the gallbladder and the duodenum, and identiied the gallstone, 6.5 cm in di- ameter in the jejunum (Fig. 3). On the next day, cholecystectomy, extraction of gallstone and closure of the bilioenteric istula were