The two subtypes of pigment gallstones, black and brown stones, differ in chemical composition and pathogenesis. We examined a black bilirubinate stone and a black phosphate stone (which represented opposite ends of the compositional spectrum of black noncarbonate stones), a black carbonate stone, and a brown pigment stone using scanning electron microscopy and microchemical techniques to determine if stone microstructure and microcomposition reflected different patterns of formation. The cross-sectional surfaces of the black bilirubinate and black phosphate stones were smooth and homogenous. Electron probe microanalysis demonstrated high concentrations of sulfur and copper in the center of the black bilirubinate stone; sulfur was in a low valence state consistent with disulfide linkages in proteins. The brown stone was rough-surfaced with lamellated bands on cross-section. The lighter-colored bands in this stone contained virtually all of the detected calcium palmitate, while the darker sections contained much more calcium bilirubinate. Plasma oxygen etching demonstrated a network of protein interdigitating with calcium bilirubinate salts in the black bilirubinate and black phosphate stones but not in the black carbonate or brown stones. Argon ion etching demonstrated that calcium bilirubinate was in a closely packed rod-shaped arrangement in all three black stones but not in the brown stone. We conclude that the marked differences in structure and composition between the black noncarbonate and brown pigment gallstones support the hypothesis that the two major pigment gallstone types form by different mechanisms, In addition, the layered structures of the black carbonate and brown stones suggest that stone growth is affected by cyclic changes in biliary composition.
The two major types of pigment gallstones are black and brown stones (1, 2). Black stones are further subclassified as either carbonate or noncarbonate based on the presence or absence of calcium carbonate (2,3). Black stones are shiny, resist manual crushing, and form predominantly in the gallbladder in sterile bile (4). They are associated with hemolysis, old age, and cirrhosis (5). Brown stones, which have also been called "bile pigment calcium" or "calcium bilirubinate" stones, have a dull brown surface and are easily crushable. On cross-section, they have a characteristic pattern of alternating lighter and darker concentric layers. Brown stones form throughout the biliary tract and are associated with stasis