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than those of younger patients.³² We can offer effective treatments to those with this cancer who have masses less than 5 cm, including eligibility for liver transplant. Therefore, screening those with cirrhosis via ultrasound every six months is of paramount importance.

Biliary disease

      As we age, the diameter of the common bile duct increases and the lithogenicity of bile increases, resulting in an increased tendency to form cholesterol and calcium bilirubinate stones.³³ It is estimated that up to 28% of men and 42% of women age 80–89 have gallstones.³⁴ In the general population, 6% of men and 9% of women have gallstones.³⁵ Asymptomatic cholelithiasis is a common occurrence in older patients, and only at most 30% of those with gallstones will become symptomatic. Symptomatic recurrent episodes of abdominal pain lasting 30–60 minutes are the usual clinical manifestation of biliary colic. Acute cholecystitis is persistent biliary pain that may be epigastric, right upper quadrant or right shoulder pain with fever, and signs of sepsis caused by gallstones, resulting in infection of the gallbladder or inflammation and infection of the gallbladder in the absence of stones (acalculous cholecystitis). The elderly frequently have atypical presentation of biliary disease and coexistent illnesses, and the increasing frailty of the elderly increases mortality. The elderly patient with cholecystitis often can present with delirium, and many have poorly localized abdominal pain. Physical diagnosis is more challenging as Murphy’s sign in older adults is poorly sensitive (48%) compared with a sensitivity of 90% in younger patients.³⁶ In a person presenting with a severe episodic or persistent epigastric right upper quadrant or right shoulder pain, or in the elderly presenting with fever or delirium, cholecystitis should be suspected. Choledocholithiasis (stones in the common bile duct) presents in a similar manner but is more likely to present with jaundice, and sepsis is more pronounced. Also, the passage of stones through the biliary tract that then obstruct the ampulla can trigger acute pancreatitis.

      If gallbladder disease is suspected, the initial test is ultrasonography, with a sensitivity of 84% and a specificity of 99%.³⁷ CT scanning is less sensitive, ranging from 55 to 80%, as many gallstones do not contain calcium and are isodense with bile. As noted above, the elderly are more likely to have acalculous cholecystitis, and cholestintigraphy (HIDA) is useful in this situation and diagnosis of acute cholecystitis. Patients can be suspected of having a common bile duct stone (choledocholithiasis) given appearance on ultrasound, jaundice, and spiking liver enzymes with abdominal pain. An elderly patient who has had a previous cholecystectomy has a larger bile duct with stasis of bile, and therefore bile duct stones are more likely to form. Ascending cholangitis and pancreatitis are complications of choledocholithiasis. Patients suspected of having choledocholithiasis can be diagnosed by magnetic resonance cholangiopancretography (MRCP), endoscopic ultrasound, or endoscopic retrograde cholangiopancreatography (ERCP). ERCP can also remove stones, treat cholangitis, and prevent recurrent pancreatitis.

      The treatment of gallstone disease depends on the symptoms, aetiology, and health of the patient. Recurrent (although not frequent) biliary colic may be observed, as complications such as acute cholecystitis develop in about 6.5% at 10 years, while asymptomatic gallstones are less likely to develop complications at a rate of 3% in 10 years.³⁸ If patients have recurrent biliary colic or acute cholecystitis and are in good condition, laparoscopic cholecystectomy is safe and effective even in patients over 90. In a study of 1007 cholecystectomies in those over 90 between 2005 and 2012, mortality was 5.5%, 3.7% for laparoscopic, and 12% for open.³⁹ If patients are too ill for cholecystectomy due to sepsis or coexistent illness, a percutaneous gallbladder drainage tube (cholecystostomy) can be placed. ERCP for choledocholithiasis is safe even in those over 80, who have about the same complication rate as those 70–79.⁴⁰

Liver transplantation

Liver transplantation is often the best treatment for advanced cirrhosis, acute hepatic failure, and some liver cancers. Carefully selected patients over 65 have a good prognosis, with five‐year survival of about 80%. In a study from the Mayo Clinic comparing 42 patients over 70 to 42 matched patients younger than 60, five‐year survival was identical.⁴¹

      The decision of when to offer a transplant to a cirrhotic patient is based on the Model for End‐stage Liver Disease (MELD). The MELD looks at several parameters in a mathematical formula to grade the cirrhotic patient’s life expectancy. Those parameters are creatinine, sodium, bilirubin, and INR. There are multiple online MELD calculators; when the MELD score is 17, a patient is likely to do better with a transplant than without one. We usually refer patients whose MELD is greater than 15 to a transplant clinic if they are a reasonable candidate. Reasonable candidates are people who are otherwise healthy in terms of no cancers, dementia, or cardiovascular disease; they can have kidney disease, as they can be listed for combined transplants. In the geriatric population over age 70, they should have a good performance status and stable and supportive home life and be likely to live 10 years with a transplant.

Conclusion

      Liver and gallbladder diseases are common in the geriatric population. When a patient presents with manifestations of liver disease such as abnormal transaminases, jaundice, ascites, bleeding, or encephalopathy, it is important to diagnose the cause and assess the prognosis. In any chronic liver disease, the patient needs to be assessed for cirrhosis using the formulas above or/and a fibroscan; if cirrhotic, the patient must be surveyed every six months for development of liver cancer or decompensation and every three years for development of varices. Fortunately, most liver diseases are treatable once diagnosed: medications can cure hepatitis C and control hepatitis B, primary biliary cholangitis, and autoimmune hepatitis. Non‐alcoholic and alcoholic liver disease are prevalent in the elderly and if caught early can be treated effectively with lifestyle changes. Drug‐induced liver disease increases as we age, and it is important to recognize this early so the offending agent can be discontinued. Geriatric patients who are otherwise healthy should be considered for liver transplantation.

      Key points

       Liver disease is common in the elderly. Most liver diseases, if caught early, can be treated effectively

       Screening for hepatitis C and nonalcoholic and alcoholic fatty liver should be done in most patients.

       Abnormal liver enzymes need to be worked up to detect liver disease at the earliest possible stage.

       Patients with liver disease need to be staged so that cirrhotic patients can receive appropriate care.

References

      1 1. De Boer JD, Block JJ, Putter H, et al. Optimizing the use of geriatric livers for transplantation in the Eurotransplant. Liver Transpl. 2019 Feb; 25(2):260–274.

      2 2. Sheedfar F, Di Biase S, Koonen D, Vinciguerra M. Liver Disease and aging: friends or foes? Aging Cell. 2013 12:950–954.

      3 3. Kim H, Kisseleva T, Brenner DA. Aging and liver disease. Curr Opin Gastroenterology. 2015 May; 31(3): 184:191.

      4 4. Deaths and hospitalization from chronic liver disease and cirrhosis – United States, 1980–1989. MMWR Morb Mortal Wkly Rep. 1993; 41:969.

      5 5. Vallet‐Pichard A, Mallet V, Nalpas B, et al. FIB‐4: an inexpensive and accurate marker of fibrosis in HCV infection. Comparison with liver biopsy and fibrotest. Hepatology. 2007; 46(1):32–36.

      6 6. Wai CT, Greenson JK, Fontana RJ, et al. A simple noninvasive index can predict both significant fibrosis and cirrhosis in patients with chronic hepatitis C. Hepatology. 2003; 38(2):518–526.

      7 7. Lim JK, Flamm SL, Singh S, Falck‐Ytter YT. Clinical Guidelines Committee of the American Gastroenterological Association. American Gastroenterological Association Institute guideline on the role of elastography in the evaluation of liver fibrosis. Gastroenterology. 2017; 152(6):1536–1543.

      8 8. Forbes A, Williams R. Increasing age: An important adverse prognostic factor in hepatitis

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