Gallstones Classification and Nomenclature

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GallstonesClassification and Nomenclature
2006.2.24Biliary Conference Review
Oh Heung Kwon M.D.
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Mixed cholesterol stone
Cholesterol stone
Black stone
Brown stone
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Introduction

• Optimal classification system for gallstones is
  needed because the etiology, pathogenesis,
  clinical features and treatment can be different
  according to the classes.
• Criterias of best classification
• Etiologic significance
• Simple terminololgy
• Relevant to the therapeutic procedures
• Internationally understood

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Historical Background

• In 1896, Naunyn based on etiologic factor
• Stasis vs Infection
• In 1924, Aschoff additional causative factor
• Metabolic derangement
• In 1981, NIH-International Workshop on Pigment
  Gallstone Disease
• Cholesterol vs Pigment (Black or Brown)
• In 1986, Gallstone Research Committee from the
  Japanese Society of Gastroenterology

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Japanese Classification
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Classification by Composition

• Cholesterol stones
• Cholesterol over 70 of the dry weight
• Pigment stones
• Calcium bilirubinate 4060 of the dry weight
• Cholesterol less than 2530
• Calcium carbonate
• Calcium phosphate
• Calcium fatty acid only in brown stone

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Composition of Pigment Stone
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Classification by anatomic location

• Cholesterol stone only in the GB
• Recently IHD stone was reported
• Brown stone usually in Bile Duct
• IHD stone contain more cholesterol and less
  bilirubin than an extrahepatic brown stone
• Black stone usually in GB

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Classification by Morphology

• External appearance
• Color
• Shape
• Internal structure
• Cross sectional shape
• Radiation vs Concentric

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Pathogenesis of cholesterol stone
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Pure Cholesterol Stone

• Single large stone
• External apperance Mulberry shape
• Internal Structure
• Radial structure from center to the periphery on
  cross section
• Pigment core Cholesterol crystals
• Pigment center less than 1/3 of diameter
• Oval to round
• White to yellow

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Pure Cholesterol Stone
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Mixed Cholesterol Stone

• Multiple stone
• External layer various
• Surface round to faceted
• Color yellowish white, yellowish brown,
  greenish brown, or black brown
• ??? Cholesterol and pigment was mixed
  throughout the layer
• Blend of a concentric and radial shape

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Mixed Cholesterol Stone
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Combination Stone

• Combined or composite stone ???
• Usually single
• Oval to Round
• Brownish or dark brown (pigment component)
• Two definite separate layers
• External layer with pigment constituents and
  inner cholesterol component or vice versa
• External layer gt 1mm

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Combination Stone
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Pathogenesis of Black Stone
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Black Pigment Stone

• Pure pigment stone
• Numerous
• Small, brittle, black, spiculated
• Commonly formed in the GB, are not associated
  with a bacterial infection
• Cross section
• Amorphous appearance

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Black Pigment Stone
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Pathogenesis of Brown Stone
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Calcium Bilirubinate Stone

• Brown Stone
• Bilirubin stone, Bile pigment calcium stone,
  earthy stone and muddy stone
• Primarily formed in the bile ducts
• Major Cause Bile stasis Bacterial infection
• External appearance various, less than 1cm
• Cut surface
• Concentric layer (lamellation)

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Calcium Bilirubinate Stone
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The End