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Miscellaneous non-tumor

Gallstone classification

Reviewer: Hanni Gulwani, M.D. (see Reviewers page)
Revised: 13 February 2013, last major update September 2012
Copyright: (c) 2003-2013, PathologyOutlines.com, Inc.


● Gallstones are composed of insoluble bile components: cholesterol, calcium bilirubinate, calcium salts (organic and inorganic), bile salts, mucin glycoproteins
● In U.S., 75-85% are cholesterol stones, 15-25% are pigment stones
● Larger stones are associated with carcinoma (Trop Gastroenterol 2012;33:39); also cholesterol, not pigment stones (Aust N Z J Surg 2000;70:667)
● Calcium stones are gray-white and amorphous; very uncommon
● Calcium carbonate may fill lumen as thick, inspissated, cream-gray to yellow-green putty-like material

Cholesterol stones


● 75-85% of all gallstones
● Only 10% are pure (at least 90% cholesterol), the remainder are mixtures with at least 60% cholesterol by weight
● Cholesterol monohydrate precipitates when no longer soluble in bile
● Initially bile supersaturation with cholesterol occurs
● Then nucleation (initial crystallization), then stone growth facilitated by bile stasis and mucin hypersecretion
● Pure and mixed occur predominantly in women
● Also associated with increasing age, obesity, rapid weight loss, diabetes, ileal disease, multiple pregnancies, total parenteral nutrition, various drugs, specific ethnic groups
● Adenomatous hyperplasia and Rokitansky-Aschoff sinuses:associated with mixed and cholesterol stones; not associated with pigment stones (Trop Gastroenterol 2002;23:25)

Gross description

● Less than 1 cm to 4 cm
● Single or multiple
● White-yellow, round/oval with crystalline cut surface

Gross images

Various images

Pigment stones


● 15-25% of all gallstones
● Associated with increasing age
● Less than 25-35% cholesterol
● Composed of calcium bilirubinate, calcium salts, mucin glycoprotein
● Brown (not black) stones associated with infected bile (usually E. coli) due to acute cholecystitis or choledocholithiasis with cholangitis
● Black stones associated with older age, chronic hemolysis, cirrhosis, sclerosing cholangitis (increased unconjugated bilirubin in bile)

Gross description

● Multiple shiny black stones, 0.2 to 5 cm, rarely brown in US (more commonly brown in Japan)

Gross images

Two pigment gallstones

End of Gallbladder > Miscellaneous non-tumor > Gallstone classification

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