Obstructive jaundice in elderly patients presents a multifaceted diagnostic and therapeutic challenge, particularly when secondary to choledocholithiasis [4]. In this case, a 78-year-old man exhibited classical symptoms of biliary obstruction, including progressive jaundice, right upper quadrant pain, dark urine, pale stools, and constitutional symptoms such as fever and vomiting. The absence of a prior biliary history or hepatotoxic exposure prompted a focused evaluation toward mechanical causes. Imaging played a pivotal role in diagnosis. Initial ultrasonography suggested proximal CBD dilatation with gallbladder sludge, raising suspicion for distal obstruction. Magnetic resonance cholangiopancreatography (MRCP), a noninvasive and highly sensitive imaging modality, confirmed a large CBD stone measuring 3.0 × 2.0 × 1.8 cm and the associated dilatation of the common hepatic and intrahepatic ducts. MRCP also revealed a contracted gallbladder with a 3 mm neck calculus and sludge-filled cystic duct consistent with chronic calculous cholecystitis. These findings ruled out hepatocellular or viral causes of jaundice, supported further by negative HAV and HEV serology, and confirmed a mechanical etiology.

Choledocholithiasis, especially with stones larger than 1.5-2.0 cm, is associated with increased failure rates for endoscopic extraction via ERCP, particularly when complicated by gallbladder disease, impacted stones, or altered anatomy [2]. In this patient, stone size (>3.0 cm), dilated cystic duct (19 mm), and associated gallbladder inflammation warranted definitive surgical management. Open cholecystectomy with CBD exploration, though more invasive than laparoscopic or endoscopic options, offered the best therapeutic approach under the given anatomical and clinical circumstances.

Intraoperative findings of a thick-walled, sludge-filled gallbladder with an impacted stone confirmed the chronicity of inflammation and obstruction. Surgical stone extraction, followed by T-tube drainage, allowed the effective decompression of the biliary tree and ensured postoperative monitoring through T-tube cholangiography if required. The patient's stable intraoperative and postoperative course with rapid resolution of jaundice and abdominal pain demonstrates the efficacy and safety of this approach even in elderly individuals.

This case exemplifies the importance of individualized management in elderly patients with complex biliary pathology. While laparoscopic cholecystectomy remains the standard for gallstone disease, technical difficulties posed by giant stones, inflamed tissue planes, and the risk of incomplete clearance in endoscopic procedures justify opting for open surgery in select cases. Literature also supports open CBD exploration as a viable and often necessary option in large stone burden or failed ERCP scenarios, particularly in high-risk patients where repeated interventions may increase morbidity [4].

Furthermore, the early recognition of obstructive features and prompt imaging, specifically MRCP, allowed for precise surgical planning and minimized the risk of complications such as ascending cholangitis, biliary sepsis, or pancreatitis [8]. Given the increasing prevalence of biliary tract disease in ageing populations, this case underscores the importance of a timely structured approach combining clinical suspicion, imaging, and appropriate surgical intervention tailored to the patient's profile.

Limitations

This is a single-patient report, so the findings lack generalizability. No comparator (ERCP/laparoscopic options) was included, limiting treatment comparison. Case reports are low-level evidence and cannot establish causation [9].