Pneumobilia, gas within the biliary tract, is due to an abnormal connection between the gastrointestinal tract and the biliary tract and is considered a serious pathology usually requiring surgical intervention. Most cases of pneumobilia are related to gallstone disease, and spontaneous biliary-enteric fistula is reported to be the most common cause of pneumobilia. Another well-documented cause of pneumobilia is a surgically created anastomosis between the biliary tract and the bowel, the Whipple procedure, and choledocho-jejunostomy, endoscopic retrograde cholangiopancreatography with papillosphincterotomy or surgical transduodenal sphincteroplasty. Transient incompetence of the sphincter of Oddi, gas-forming infections, and trauma have also been reported to cause pneumobilia. We present the case of a 74-year-old woman with asymptomatic cholelithiasis, pneumobilia and cholecystoduodenal fistula treated with cholecystectomy, fistula closure with Graham patch, Stamm-Kader gastrostomy and needle catheter jejunostomy. On the first postoperative day she developed a biliary duodenal fistula that required nutritional support with parenteral, enteral nutrition and octreotide acetate with fistula closure 2 weeks later. We review the etiology, surgical treatment and economic burden. Laparoscopic cholecysto-fistulectomy by skilled laparoscopic surgeons can be adopted as a first-choice treatment for cholecystoduodenal fistula to reduce morbility risks and costs.