The prognosis in patients with acute cholangitis is poor, particularly when the cholangitis is 'severe' as defined by the presence of hypotension and/or confusion. This prospective study evaluates 16 elderly patients with acute cholangitis ('severe' in 11) due to stones in whom endoscopic biliary decompression was attempted. It was technically successful on 13 (81%) of the 16 occasions and the cholangitis rapidly resolved in these patients. In seven of 13, this was the definitive treatment while six underwent subsequent surgery consisting of: cholecystectomy or cholecystostomy (five) and secondary bile duct exploration (one). Two patients died following laparotomy for stones that were not amendable to endoscopic removal. Urgent endoscopic retrograde choledochography is recommended in elderly patients with acute cholangitis, because it confirms the diagnosis and allows decompression of the biliary tract by sphincterotomy. This stabilizes the patient's general condition and facilitates subsequent open surgery when required.