The outcome of 68 patients with asymptomatic cholelithiasis undergoing laparotomy for other conditions was reviewed to determine those most likely to become symptomatic postoperatively. Thirty-seven patients (54%) became symptomatic postoperatively. Eight patients (22%) required cholecystectomy within 30 days of operation or within the same hospitalization. These patients fasted for a longer period of time postoperatively (15 +/- 21 vs 4 +/- 3 days) than those undergoing later cholecystectomy. Significantly more of these patients required transfusion (38% vs 7%), mechanical ventilation (50% vs 11%), and total parenteral nutrition (50% vs 18%). Cholelithiasis frequently becomes symptomatic after laparotomy for other intra-abdominal conditions. Patients who require mechanical ventilation, transfusions, and parenteral nutrition and who are slow to resume enteral nutrition are more likely to require early cholecystectomy. Concomitant cholecystectomy adds minimal morbidity to other procedures and should be undertaken unless specific contraindications exist, particularly in this high-risk group.