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Biliary tract diseases in the elderly: management and outcomes
  1. Endoscopy Section,
  2. Beth Israel Medical Center North Division,
  3. New York, New York 10128, USA

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Diseases affecting the gall bladder and bile ducts occur commonly in the elderly. By the age of 70, cholelithiasis, the most frequently occurring disorder affecting these organ systems, and its sequela, choledocholithiasis, are found in 33% of the population of the United States.1 The challenges facing the clinician responsible for treating elderly patients with biliary tract diseases are: (1) developing an astute clinical acumen while assimilating the ubiquitous nature of these disorders in the elderly, especially when compared with the presenting complaints of younger individuals, and (2) acknowledging the increasing number of treatment options now available. In this review, we focus on gallstone diseases, including cholelithiasis, cholecystitis, choledocholithiasis, with and without cholangitis, and malignant biliary strictures, far and away the most common disorders of the biliary tree affecting the aged population.

Gallstones and cholecystitis

Asymptomatic gallstones are a common feature of ageing as time, gall bladder dysfunction and the increasing lithogenicity of bile seem to predispose the gall bladders of the more elderly population to precipitation of supersaturated bile and the concomitant crystallisation of cholesterol or calcium bilirubinate into stone material. While it has been accepted dogma that prophylactic surgery should not be recommended in asymptomatic patients, the longer one has gallstones, the more likely one is to develop cholecystitis and biliary colic. The dilemma clinicians and surgeons encounter is tackling this problem and arriving at the decision on whom to operate and the timing of surgery.

Most patients with gallstones never develop acute cholecystitis, and among those who experience an episode of biliary colic, nearly half will never experience a second episode of colic within five years. Such an outcome could justify a “wait-and-see” approach for most elderly patients. However, there are several factors which contradict such a decision in the aged. Firstly, the presentation of colic in the elderly patient …

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