Biliary tract disease in the aged.

Gallstone disease occurs in 20% to 30% of the elderly, is usually silent, and is rarely fatal. Silent GSD requires no treatment. Symptomatic GSD can be treated surgically, nonsurgically, or, if there are minimal symptoms, expectantly. The decision is based largely on physician experience and informed patient preference. Nonsurgical treatment is evolving and has particular appeal for the elderly but does have restricting eligibility requirements and limited efficacy. For acute cholecystitis, early surgery is advisable, except for high-risk patients, in whom conservative treatment or cholecystostomy may be preferable. For choledocholithiasis with persistent obstruction or cholangitis and for severe biliary pancreatitis, ERCP with sphincterotomy and stone removal is usually advisable. Benign biliary strictures are infrequent, usually iatrogenic, and a diagnostic consideration whenever biliary obstruction develops within a year after cholecystectomy. Treatment is usually surgical and not always successful. Biliary strictures in patients with ulcerative colitis suggest PSC. Malignant biliary obstruction is common in the elderly and with a few exceptions is rarely curable. Palliation is often achieved by endoscopic stenting.