Aim This narrative review aims to critically evaluate current evidence comparing surgical and non-surgical management strategies for acute cholelithiasis in elderly patients, focusing on outcomes, risks, and decision-making factors unique to this population. Material and Methods A comprehensive literature search was performed in MEDLINE®, Embase™, PubMed®, and Google Scholar™ using the terms: “acute cholecystitis,” “cholelithiasis,” “elderly,” “surgical management,” “laparoscopic cholecystectomy,” “non-surgical,” and “percutaneous cholecystostomy.” Studies published between 2005 and 2025 were included if they evaluated outcomes such as morbidity, mortality, recurrence, and hospital stay in elderly patients. Both surgical and non-operative management strategies were compared, including antibiotic therapy and cholecystostomy. Articles were selected in accordance with PRISMA principles. Conclusions Laparoscopic cholecystectomy remains the gold standard for acute gallstone disease but carries higher morbidity and mortality in elderly patients due to comorbidities and frailty. Non-operative approaches such as percutaneous cholecystostomy, or antibiotic therapy may reduce immediate surgical risk but are associated with higher recurrence and readmission rates. Optimal management requires an individualised, multidisciplinary approach considering physiological reserve, inflammatory markers, and patient preference. More prospective studies are needed to standardise risk stratification and management pathways specific to geriatric patients with acute cholelithiasis. Keywords Cholelithiasis; Laparoscopic cholecystectomy; Elderly; Non-operative management; Percutaneous cholecystostomy