Surgery in the elderly: observations on the pathophysiology and treatment of cholelithiasis

Biliary tract disease is particularly prevalent in older persons, and is the leading indication for acute abdominal surgery in the elderly. The complications of biliary stone disease are more insidious in the elderly, and the recognition of "symptomatic" disease is often delayed. The unreliable manifestations of biliary tract pathology result in a higher morbidity and mortality of the disease, and a large number of emergency operations. Recent studies suggest that the pathophysiology of cholelithiasis is specifically altered in the elderly. Pigmented gallstones, which are more common in the elderly, are thought to result from the action of bacterial enzymes that deconjugate bilirubin and form insoluble bile salts; bacterial contamination of the extrahepatic biliary system is more frequent in elderly patients. Gallbladder stasis may be due to age-related changes in the response of gallbladder musculature to the kinetic action of cholecystokin (CCK), possibly through a decrease in CCK receptor affinity or availability. Other hormonal factors which inhibit choleresis, such as pancreatic polypeptide, are increased with aging as well. Current efforts are being directed toward closer surveillance and discovery of cholelithiasis, and improved outcomes of therapy have been aided by the development of "minimally invasive" approaches to the treatment of cholelithiasis in the elderly.