[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [General pathology](https://durgical.com/en/general-pathology/) › [Liver and gallbladder](https://durgical.com/en/general-pathology/areas/liver/) › Gallstones: cholesterol vs pigment

# Gallstones: cholesterol vs pigment

- Lesion

Gallstones form when bile has too much cholesterol or bilirubin; most cause no symptoms, but they can block ducts and inflame the gallbladder.

Updated Nov 12, 2026

## Key points

- Cholesterol stones: most common in Western and Latin American populations; risk with female sex, pregnancy and estrogens, obesity, rapid weight loss, age, family history, certain indigenous ancestries.
- Four conditions for cholesterol stones: supersaturation, hypomotility (stasis), accelerated nucleation, mucus hypersecretion.
- Black pigment stones: chronic hemolysis (sickle cell disease, hereditary spherocytosis), cirrhosis, ileal disease (Crohn) with bile acid loss.
- Brown pigment stones: infected intrahepatic and common ducts (bacteria and parasites), more frequent in Asia.
- Most cholesterol stones are radiolucent; many pigment stones contain calcium and are radiopaque.
- Gallstone disease is especially frequent in Chile and other Andean populations.

## What it is

Gallstones (cholelithiasis) are very common. Cholesterol stones form when bile is supersaturated with cholesterol, gallbladder motility is reduced, nucleation is accelerated and mucus traps crystals. Pigment stones contain calcium bilirubinate: black stones form in sterile bile with chronic hemolysis or cirrhosis, brown stones in infected bile ducts. Most stones are silent; complications include cholecystitis, choledocholithiasis, cholangitis, pancreatitis and gallbladder cancer.

## Step by step

- The liver secretes more cholesterol into bile, or fewer bile acids and phospholipids to keep it dissolved.
- Bile becomes supersaturated with cholesterol.
- The gallbladder empties poorly (stasis), so bile stays concentrated longer.
- Cholesterol crystals nucleate; mucin from the gallbladder wall traps them as sludge.
- Crystals grow into stones that may block the cystic or common bile duct.

## Cholesterol vs pigment gallstones

| Feature | Cholesterol stones | Black pigment stones | Brown pigment stones |
| --- | --- | --- | --- |
| Composition | Mostly crystalline cholesterol | Calcium bilirubinate polymers, calcium salts | Calcium bilirubinate with fatty acid soaps |
| Site | Gallbladder | Gallbladder | Intrahepatic and extrahepatic ducts |
| Setting | Female sex, obesity, estrogens, rapid weight loss, age | Chronic hemolysis, cirrhosis, ileal disease | Bile duct infection, parasites, stasis |
| Appearance | Pale yellow, hard, faceted; mostly radiolucent | Small, black, many; often radiopaque | Soft, greasy, brown; radiolucent |

## Clinical notes

- Biliary colic: post-prandial right upper quadrant pain from a stone impacting the cystic duct.
- Complications: acute cholecystitis, choledocholithiasis with jaundice, ascending cholangitis, gallstone pancreatitis, gallstone ileus, gallbladder carcinoma.

## Memory aid

Cholesterol stones follow the classic list: female, fertile, fat, forty; black stones follow broken red cells; brown stones follow bugs.

## Test yourself

Think of the answer, then tap the question to see it.

## Which four conditions favour cholesterol gallstones?

Supersaturation of bile with cholesterol, gallbladder hypomotility, accelerated crystal nucleation and mucus hypersecretion.

## Why do patients with sickle cell disease form gallstones?

Chronic hemolysis increases unconjugated bilirubin in bile, which precipitates as calcium bilirubinate (black pigment stones).

## Where do brown pigment stones typically form?

In infected intrahepatic and extrahepatic bile ducts, often with bacteria or parasites.

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## Elsewhere in DurgiPedia

- [Bile and the enterohepatic circulation](https://durgical.com/en/physiology/bile-and-the-enterohepatic-circulation/)
- [Bile acid synthesis](https://durgical.com/en/biochemistry/topics/bile-acid-synthesis/)
- [Cholesterol](https://durgical.com/en/biochemistry/molecules/cholesterol/)
- [Gallbladder and bile ducts](https://durgical.com/en/histology/gallbladder-and-bile-ducts/)

## Connections

## Related 5

- [Cholecystitis: acute, acalculous and chronic](https://durgical.com/en/general-pathology/cholecystitis-acute-acalculous-and-chronic/)
- [Gallbladder carcinoma](https://durgical.com/en/general-pathology/gallbladder-carcinoma/)
- [Large bile duct obstruction](https://durgical.com/en/general-pathology/large-bile-duct-obstruction/)
- [Acute pancreatitis: causes, and how trypsin starts self-digestion](https://durgical.com/en/general-pathology/acute-pancreatitis-causes-and-how-trypsin-starts-self-digestion/)
- [Pathologic calcification: dystrophic vs metastatic](https://durgical.com/en/general-pathology/pathologic-calcification-dystrophic-vs-metastatic/)

## Related conditions 9

- [Gallstones (cholelithiasis)](https://durgical.com/en/conditions/gallstones/)
- [Choledocholithiasis](https://durgical.com/en/conditions/choledocholithiasis/)
- [Acute cholecystitis](https://durgical.com/en/conditions/acute-cholecystitis/)
- [Acute cholangitis](https://durgical.com/en/conditions/acute-cholangitis/)
- [Acute pancreatitis](https://durgical.com/en/conditions/acute-pancreatitis/)
- [Hereditary spherocytosis](https://durgical.com/en/conditions/hereditary-spherocytosis/)
- [Sickle cell disease](https://durgical.com/en/conditions/sickle-cell-disease/)
- [Crohn disease](https://durgical.com/en/conditions/crohn-disease/)
- [Obesity](https://durgical.com/en/conditions/obesity/)

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Educational content on the mechanisms of disease; not a diagnostic or treatment guide and no substitute for a health professional's advice. No doses are given.

Sources: [Gallstones (Cholelithiasis)](https://www.ncbi.nlm.nih.gov/books/NBK459370/) (StatPearls (NCBI Bookshelf), 2026); [Choledocholithiasis](https://www.ncbi.nlm.nih.gov/books/NBK441961/) (StatPearls (NCBI Bookshelf), 2026).

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Representative model, for educational purposes only.

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License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/general-pathology/gallstones-cholesterol-vs-pigment/