Gallstone disease is divided into two types with different nature: gallbladder stones and bile duct stones. Most domestic bile duct stones are primary hepatic bile duct stones, with bilirubin as the main component, and the age of onset is mostly middle-aged; gallstone disease in large and medium-sized cities and southeastern coastal areas is predominantly cholesterol mixed stones in gallbladder stones. Although middle-aged women are risk factors for the development of gallbladder stones, the gender difference disappears with age and the overall incidence of the population increases significantly, resulting in the majority of elderly gallstone patients having gallbladder stones as well as secondary bile duct stones originating from the gallbladder. Outpatient visits for geriatric gallstone disease are infrequent, and the majority of clinical visits seen are in the form of acute attacks. In a survey of elderly patients aged 65 years and older with acute abdomen, gallstone induced biliary disease was reported to account for approximately one quarter of acute abdominal conditions. Thus, gallstone disease is a major cause of acute abdomen in the elderly. Complications of geriatric cholelithiasis are insidious, often difficult to diagnose and treat because of atypical symptoms, and because the elderly are associated with a variety of diseases such as organ dysfunction, which leads to great surgical risks, and even appears to be anti-operative indications, making the incidence of complications and mortality of geriatric cholelithiasis higher. Geriatric cholelithiasis obviously has its own characteristics in terms of pathophysiology and clinical management. I. Pathophysiological changes underlying gallstone disease in the elderly After gallbladder stones are formed, they can be divided into asymptomatic and symptomatic phases. Clinically, symptomatic gallbladder stones are more common and manifest as multiple acute attacks of chronic cholecystitis. Some further develop into acute purulent cholecystitis, or gallbladder duct obstruction to form gallbladder effusion. Once the gallbladder stones develop into secondary bile duct stones, acute cholangitis may develop, manifesting as Charcot’s triad, and obstruction of the lower bile duct may produce acute cholangioadenitis or obstructive yellowness. Compression of the common bile duct by cystic duct stones leads to Mirizzi’s syndrome. Severe recurrent cholecystitis can cause atrophy of the gallbladder and even produce lesions such as gallbladder and bile duct cancer. Geriatric cholelithiasis is more likely to lead to biliary complications if multiple small gallbladder stones are predominant. Geriatric cholelithiasis is also characterized by insidious complication symptoms, which leads to delayed diagnosis and treatment, missing the opportunity for elective surgery and often becoming an emergency procedure. Even in acute abdomen, abdominal signs are milder in elderly patients with cholelithiasis, with only half of the patients presenting with right upper abdominal pain and Muphy’s sign. A retrospective study of patients older than 65 years with acute cholecystitis found that more than 60% had no right upper abdominal or back pain at presentation, more than 50% had no fever, 41% had normal blood leukocytes, and 5% of elderly patients had no abdominal pain at all. The incidence of severe cholangitis, shock, altered consciousness, peritonitis, and renal failure is higher in elderly patients compared to other age groups. These pathophysiologic features determine the high incidence of complications and mortality in geriatric cholelithiasis. Not only are there specific pathological changes in gallstone disease in the elderly, but the elderly themselves also suffer from tissue and organ decline and diminished function with increasing age. The elderly are often complicated by diseases of important organs, especially cardiovascular and respiratory diseases that cause cardiopulmonary dysfunction, which seriously affects the treatment of geriatric cholelithiasis, and the treatment is especially difficult under emergency conditions. II. Treatment decisions for geriatric cholelithiasis Prophylactic cholecystectomy is generally not recommended for asymptomatic gallstone patients, but elderly patients with cholelithiasis are at a higher risk of biliary complications, making them unsuitable for a conservative wait-and-see treatment strategy. The surgical approach to gallstone disease has undergone a dramatic change since the 1990s. Laparoscopic techniques have become the gold standard in the treatment of gallstone disease. Although elderly patients with gallstone disease have a long history of recurrent attacks resulting in gallbladder atrophy and local adhesions, unclear anatomic relationships, and increased risk of surgical malpractice; at the same time, elderly patients have poor systemic status and often combine multiple diseases, making perioperative management more difficult, with the improvement of surgical techniques and the strengthening of perioperative monitoring and treatment capabilities, it is generally safe to perform elective biliary surgery in elderly gallstone patients. Therefore, in principle, the management of gallstone disease and its complications in the elderly should be elective, and a less invasive surgical option should be chosen by combining the systemic conditions. Once gallstone-related complications occur in elderly patients, the operative mortality and complication rates are significantly higher than those of elective surgery. The postoperative mortality rate for acute septic cholangitis in the elderly is 20 times higher than that for elective biliary surgery, and the mortality rate for acute cholecystitis is 12% higher. Because of the lack of hyperthermia and typical abdominal symptoms in elderly patients with biliary complications, clinicians often try to treat patients conservatively for a period of time before deciding on a treatment plan because they are concerned about their ability to tolerate surgical trauma, but this often delays surgery and misses the opportunity to save patients’ lives. For this reason, it is recommended that biliary drainage should be performed immediately in elderly patients with cholangitis when they are in shock or have altered consciousness. However, successful biliary drainage does not completely guarantee the avoidance of postoperative complications and death in elderly patients. One study reported that the mortality rate of emergency gallstone surgery in patients aged 80 years and older was 11.8%, mostly due to pulmonary complications and multiple organ failure; the complication rate was 50%, with incisional infections, urinary tract infections, and pulmonary complications; and preoperative jaundice was also an important factor affecting liver function and patient prognosis. In conclusion, the use of aggressive treatment options, including endoscopic or minimally invasive surgery, in the emergency management of geriatric gallstone disease can help save patients’ lives. Meanwhile, elective surgery is significant for the treatment of gallstone disease in the elderly. In conclusion, with the advent of an aging society, gallstone disease, a common surgical condition, has become one of the major health risks in the elderly. For elderly patients who have been diagnosed with gallstone disease, early surgery should be strived for when conditions allow, in order to reduce the risk of biliary complications caused by gallstones; for elderly patients who have already developed biliary complications, they should also be evaluated comprehensively for systemic conditions and local conditions, and aggressive treatment should be selected, rather than denying the value of surgical treatment by advanced age.