Endoscopic Management of Choledocholithiasis in the Elderly: Balancing Safety and Effectiveness in the Aging Era

Endoscopic retrograde cholangiopancreatography (ERCP) is recommended as a first-line treatment for bile duct stones in multiple guidelines. Although ERCP is an established and effective procedure, it is associated with early adverse events, particularly in elderly patients. Older individuals frequently have multiple comorbidities, are often treated with antithrombotic agents, and may have underlying oropharyngeal dysphagia, all of which increase the risk of complications such as bleeding, hypotension, and aspiration pneumonia. In addition, bile duct stones in elderly patients tend to be larger and more numerous, and the high prevalence of periampullary diverticula may limit the extent of endoscopic sphincterotomy, thereby prolonging procedure time and increasing procedural complexity. Recent evidence has also demonstrated an association between frailty and post-ERCP mortality. While definitive stent placement without stone extraction could be a treatment option, it should only be considered in very elderly patients with significant frailty and limited life expectancy since endoscopic stone removal reduces long-term biliary events and subsequent mortality. In patients with concomitant cholangitis, urgent biliary drainage reduces mortality regardless of severity. However, because elderly patients are at increased risk of periprocedural hypotension and aspiration pneumonia, urgent ERCP should be performed with careful monitoring and meticulous supportive management. In summary, treatment decisions should not be based solely on chronological age but should incorporate a comprehensive assessment of overall physical condition, including frailty.