A retrospective review of 88 male patients older than 60 years of age with billiary tract disease showed a mortality of 6.8%. More than 40% of the patients (39 of 88) had acute cholecystitis. Medical therapy failed for almost all of the patients (38 of 39) with acute inflammatory disease and they then required an operation during their initial hospitalization. In this acute disease group, 21% had empyema of the gallbladder, 18% had gangrenous cholecystitis or free perforation of the gallbladder, and 15% had subphrenic or liver abscesses. Escherichia coli and Klebsiella were obtained from 78% of the bile cultures, and obligate anaerobes were present in 25% of them. A delay in diagnosis and operation occurred in 33% of the patients with acute disease. Factors responsible for this delay included a deceptively benign clinical presentation and the requirement for prolonged resuscitation. Since response to conservative measures is unlikely in the elderly patient with acute cholecystitis, optimal management consists of resuscitation and prompt operation for control of infection.