Pathogenesis of Pigment Stones.

Pigment gallstones are complex mixtures of abnormal insoluble calcium salts of unconjugated bilirubin along with inorganic calcium salts.[63] Unconjugated bilirubin is normally a minor

component of bile but increases when infection of the biliary tract leads to release of microbial b-glucuronidases, which hydrolyze bilirubin glucuronides. Thus, infection of the biliary

tract, as with Escherichia coli or Ascaris lumbricoides or by the liver fluke Opisthorchis sinensis, increases the likelihood of pigment stone

Figure 18-49Schematic representation of the four contributing factors for cholelithiasis: supersaturation, gallbladder hypomotility, crystal nucleation, and accretion within the gallbladder

mucous layer.

Figure 18-50Cholesterol gallstones. Mechanical manipulation during laparoscopic cholecystectomy has caused fragmentation of several cholesterol gallstones, revealing interiors that are

pigmented because of entrapped bile pigments. The gallbladder mucosa is reddened and irregular as a result of coexistent chronic cholecystitis.

Figure 18-51Pigment gallstones. Several faceted black gallstones are present in this otherwise unremarkable gallbladder from a patient with a mechanical mitral valve prosthesis, leading

to chronic intravascular hemolysis.

Figure 18-52Acute calculous cholecystitis; the stone was not photographed.

Figure 18-53Chronic cholecystitis with cholesterol stones. The gallbladder wall is thickened and gray-white, owing to fibrosis and inflammation. The mucosa is effaced. Multiple faceted

cholesterol gallstones are present within the lumen. The exterior of the specimen is black as a result of India ink application.

Figure 18-54Biliary atresia, schematized to show the pattern of biliary tract injury.

Figure 18-55Gallbladder adenocarcinoma. A, The opened gallbladder contains a large, exophytic tumor that virtually fills the lumen. B, Malignant glandular structures are present within a

densely fibrotic gallbladder wall.

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