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Classification and pathogenesis of pigment gallstones

  • R. D. Soloway
  • P. F. Malet

Abstract

Pigment gallstones contain a variety of insoluble calcium salts. Calcium bilirubinate is usually the major component while cholesterol accounts for less than 50% by weight. There are two types of pigment stones, identifiable by epidemiological, clinical, morphological and compositional features. The pathogenesis of each is conjectural. Black stones have a glass-like featureless appearance on fracturing. They form in the gallbladder and do not recur after cholecystectomy. They are found in 60–80% of patients with haemolysis, but are usually found in the general population in elderly, thin patients without haemolysis. Calcium phosphate and carbonate are frequently also present and may predominate. The remainder consists primarily of a protein network, mostly glycoprotein, which may slowly trap and interdigitate with a network of microcrystalline calcium salts. Brown stones have a rough surface and on cross-section demonstrate alternating brown and tan layers containing predominantly calcium bilirubinate and calcium salts of fatty acids respectively. Glycoproteins are much less prominent. Brown stones are associated with stasis, bacterial infection and parasites, whereas black stones are found in sterile bile. The female:male ratio for both types is 1.25:1. In the West, brown stones usually form in the common duct, more than a year after cholecystectomy for cholesterol or black stones. In the Orient, brown stones form de novo anywhere within the biliary tract and are the major cause of intrahepatic stones, cholangiohepatitis and liver failure. They are believed to form by rapid non-crystalline precipitation of calcium salts of bilirubin and fatty acids following enzymatic hydrolysis of bilirubin glucuronide and lecithin. These enzymes could originate from bacteria and/or from damaged biliary epithelium. Thus, aside from being pigmented and containing calcium bilirubinate, there are no common features in the pathogenesis of black and brown pigment stones, and they form in mutually exclusive circumstances.

The epidemiological data presently available support the hypothesis that the conditions under which pigment stones form are not only separate from those for cholesterol stones but prevent the simultaneous formation of cholesterol stones. Similarly the conditions for formation of the two subtypes of pigment stones — black and brown stones — preclude simultaneous formation of the other. This presentation will provide a classification of pigment stones and summarize the available chemical, structural and epidemiological data, all of which support the above hypotheses.

Keywords

Calcium Salt Cholesterol Stone Pigment Stone Intrahepatic Stone Calcium Bilirubinate 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Soloway, R. D., Trotman, B. W. and Ostrow, J. D. (1977). Progress in gastroenterology, pigment gallstones. Gastroenterology, 72, 167–182PubMedGoogle Scholar
  2. 2.
    Trotman, B. W. and Soloway, R. D. (1982). Pigment gallstone disease: summary of the National Institutes of Health International Workshop. Hepatology, 2, 879–884PubMedCrossRefGoogle Scholar
  3. 3.
    Lamont, J. T., Ventola, A. S., Trotman, B. W. and Soloway, R. D. (1983). Mucin glycoprotein content of human pigment gallstones. Hepatology, 3, 377–382PubMedCrossRefGoogle Scholar
  4. 4.
    Malet, P. F., Takabayashi, A., Trotman, B. W., Soloway, R. D. and Weston, N. E. (1984). Black and brown pigment gallstones differ in microstructure and microcomposition. Hepatology, 4, 227–234PubMedCrossRefGoogle Scholar
  5. 5.
    Tabata, M. and Nakayama, F. (1981). Bacteria and gallstone: etiological significance. Dig. Dis. Sci., 26, 218–224PubMedCrossRefGoogle Scholar
  6. 6.
    Goodhart, G. L., Levison, M. E., Trotman, B. W. and Soloway, R. D. (1978). Pigment vs cholesterol cholelithiasis. Bacteriology of gallbladder stone, bile and tissue correlated with biliary lipid analysis. Am. J. Dig. Dis., 23, 877–882PubMedCrossRefGoogle Scholar
  7. 7.
    Malet, P. F., Huang, G., Long, W. B., Trotman, B. W. and Soloway, R. D. (1982). The post-cholecystectomy interval influences the composition of common bile duct gallstones. Hepatology, 2, 843 (abstract)CrossRefGoogle Scholar
  8. 8.
    Nagase, M., Hikasa, Y., Soloway, R. D., Tanimura, H., Setoyama, M. and Kato, H. (1980). Gallstones in Western Japan. Factors affecting the prevalence of intrahepatic gallstones. Gastroenterology, 78, 684–690PubMedGoogle Scholar
  9. 9.
    Trotman, B. W., Ostrow, J. D., Soloway, R. D., Cheong, E. B. and Longyear, R. B. (1974). Pigment vs cholesterol cholelithiasis: comparison of stone and bile composition. Am. J. Dig. Dis., 19, 585–590PubMedCrossRefGoogle Scholar
  10. 10.
    Trotman, B. W. and Soloway, R. D. (1975). Pigment vs cholesterol cholelithiasis: clinical and epidemiological aspects. Am. J. Dig. Dis., 20, 735–740PubMedCrossRefGoogle Scholar
  11. 11.
    Hikasa, Y., Nagase, M., Soloway, R. D., Tanimura, H., Setoyama, M. and Kato, H. (1981). Gallstones in Western Japan. Epidemiologic factors affecting the type and location of gallstones. Arch. Jap. Chir., 50, 272–288Google Scholar
  12. 12.
    Dolgin, S. M., Schwartz, J. S., Kressel, H. Y., Soloway, R. D., Miller, W. T., Trotman, B. W., Soloway, A. S. and Good, L. I. (1981). Identification of patients with cholesterol or pigment gallstones using discriminant analysis of radiographic features. N. Engl. J. Med., 304, 808–811PubMedCrossRefGoogle Scholar
  13. 13.
    Schoenfield, L. J., Lachin, J. M., and the Steering Committee for the National Cooperative Gallstone Study (1981). Chenodiol (chenodeoxycholic acid) for the dissolution of gallstones: The National Cooperative Gallstone Study. Ann. Intern. Med., 95, 257–282PubMedGoogle Scholar
  14. 14.
    Soloway, R. D., Takabayashi, A., Rios-Dalenz, J., Nakayama, R., Tandon, R. K., Trotman, B. W. and Henson, D. E. (1981). Geographic differences in the operative incidence and type of pigment gallstones and in the noncholesterol components of cholesterol gallstones. Hepatol. Rapid Lit. Rev., 11, 1637–1638Google Scholar
  15. 15.
    Trotman, B. W., Morris, T. A. III, Sanchez, H. M., Soloway, R. D. and Ostrow, J. D. (1977). Pigment vs cholesterol cholelithiasis. Identification and quantification by infrared spectroscopy. Gastroenterology, 72, 495–498PubMedGoogle Scholar
  16. 16.
    Black, B. F., Carr, S. H., Ohkubo, H. and Ostrow, J. D. (1982). Equilibrium swelling of pigment gallstones: evidence for a network polymer structure. Biopolymers, 21, 601–610PubMedCrossRefGoogle Scholar
  17. 17.
    Ziln, K. W., Grant, D. M., Englert, E. E. Jr et al. (1980). The use of solid 13.C nuclear magnetic resonance for the characterization of cholesterol and bilirubin pigment composition of human gallstones. Biochem. Biophys. Res. Commun., 93, 857–866CrossRefGoogle Scholar
  18. 18.
    Soloway, R. D., Trotman, B. W., Yu, J. M., Malet, P. F. and Falk, H. (1983). Unconjugated bilirubin is quantitatively the predominant pigment in pigment gallstones. Hepatology, 3, 836 (abstract)Google Scholar
  19. 19.
    Malet, P. F., Williamson, C., Trotman, B. W. and Soloway, R. D. (1982). Cross-sectional microstructure and composition of cholesterol gallstones identify the distribution of calcium salts. Hepatology, 2, 743 (abstract)Google Scholar

Copyright information

© MTP Press Limited 1984

Authors and Affiliations

  • R. D. Soloway
  • P. F. Malet

There are no affiliations available

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