A clinical photograph displaying the cross-sectional morphology of three distinct types of human gallstones (cholelithiasis), presented with a centimeter scale for size reference. Stone A represents a pure cholesterol gallstone, characterized by a pale white color and a radially crystalline internal structure extending from the center to the periphery. Stone B depicts a mixed cholesterol gallstone, featuring a heterogeneous internal appearance with alternating light (cholesterol) and dark (pigment) concentric, crescentric layers. Stone C illustrates a pigment gallstone, showing a uniformly dark, black coloration throughout its cross-section with an irregular, rough surface texture. The image serves as an educational reference for distinguishing gallstone subtypes based on macroscopic internal and external characteristics, including color distribution, layering patterns, and crystalline arrangement.

This gross pathology photograph documents massive cholelithiasis with densely packed pigment stones within the gallbladder. The left panel shows a partially opened gallbladder specimen with a pale mucosal surface and residual bile, while the right cluster consists of numerous dark stones laid out for visualization. The stones are black to dark green in color, with a mulberry-like, irregular morphology and spiculated or molded contours. They are small in size, typically 0.2–0.5 cm, but a minority can reach larger dimensions; in this case, a very heavy burden is present with approximately 130 stones. The stones are hard and resistant to crushing, contrasting with brown pigment or cholesterol stones which are usually softer. The overall appearance is characteristic of black pigment gallstones (calcium bilirubinate) formed in the setting of chronic biliary infection or hemolysis. This stone type is often radiopaque and may be associated with pigment deposition in the gallbladder mucosa and chronic cholecystitis. Clinically, pigment stones accompany biliary stasis and inflammatory changes and increase risk for gallstone-related complications such as biliary colic, cholecystitis, or pancreatitis. This specimen provides a valuable teaching example for stone morphology, composition, and differential diagnosis between pigment and cholesterol stones, and illustrates the extreme stone burden possible in pigment stone disease.

Gross pathology photograph of brown pigment gallstones (choleliths) retrieved from the gallbladder, featuring a cross sectional view of laminated surfaces. These pigment stones are composed of calcium salts of unconjugated bilirubin (monomeric calcium bilirubinate) embedded in a glycoprotein matrix, with interleaved calcium salts of fatty acids such as palmitate and stearate. Relative to black pigment stones, brown pigment stones contain a higher proportion of cholesterol and frequently incorporate small quantities of bile salts, phospholipids, and bacterial residues. The cut surface is stratified (lamellated), with bilirubinate-rich layers alternating with calcium palmitate-rich layers, reflecting alternating deposition of pigment and fatty acid calcium salts during growth. The overall appearance on the specimen can closely resemble fecal matter, a feature highlighted in this photograph. Image courtesy of Dr. Ibrahim Zardawi, used with permission. Clinically, brown pigment stones are associated with biliary infection and stasis, and are more common in settings of cholangitis or enteric bacterial activity producing beta-glucuronidase that promotes pigment precipitation. These stones are typically radiolucent and may be mixed with cholesterol components. They contribute to cholelithiasis risk and may require cholecystectomy. Potential diagnostic uses include educational reference for gallstone composition, histologic correlation, and differential diagnosis with black pigment stones and cholesterol stones.

This is a macroscopic gross pathology photograph of a cholecystectomy specimen demonstrating cholelithiasis confined to the gallbladder. The lumen is densely packed with multiple cholesterol stones, disc-like to rounded, with smooth to slightly faceted surfaces and a pale yellow to tan coloration. Individual calculi measure approximately 0.5–1.5 cm in diameter, as inferred from the included 1 cm scale bar. The surrounding gallbladder wall is partially exposed with a red, friable serosa and mucosa not fully visible due to tissue handling. The stones appear radiolucent on plain radiographs in life; here they are visible only as macroscopic calculus clusters. The specimen illustrates classic features of cholesterol stones: low pigment, cholesterol-supersaturated bile and hypomotility contributing to stone formation. The image is optimized to highlight gross morphology suitable for educational and diagnostic reference in surgical pathology, hepatobiliary disease, and gastroenterology. Clinically, cholelithiasis is common in adults and may present with biliary colic or cholecystitis; cholesterol stones constitute the majority of gallstones. The image provides visual confirmation of stone burden within the gallbladder and can aid differential with pigment stones or mixed stones and in teaching radiology-pathology correlations. This image illustrates macroscopic appearance for teaching gross pathology and correlating with surgical pathology findings globally.

This diagnostic ultrasound image in the transverse plane demonstrates a gallbladder with classic sonographic findings of acute cholecystitis and cholelithiasis. A large, prominent hyperechoic gallstone is visible within the lumen of the gallbladder, exhibiting a characteristic posterior acoustic shadow that extends inferiorly, indicating the dense nature of the calculus. The gallbladder wall is clearly labeled and appears significantly thickened (measuring 0.71 cm as per the distal measurement marker), which is a primary diagnostic criterion for inflammation. Additionally, there is evidence of pericholecystic edema, visualized as a hypoechoic, hazy area surrounding the outer wall of the gallbladder. These features—cholelithiasis, wall thickening, and pericholecystic fluid/edema—collectively support a diagnosis of acute cholecystitis. The image serves as an educational tool for identifying the sonographic hallmarks of biliary disease in a clinical setting.

This diagnostic ultrasound image displays a dual-view scan of the gallbladder within the upper right quadrant. The primary finding consists of multiple hyperechoic foci located within the dependent portion of the gallbladder lumen. These structures exhibit high echogenicity relative to the surrounding anechoic bile. Distinctive posterior acoustic shadowing is visible deep to these foci, where the ultrasound signal is attenuated, a classic hallmark of cholelithiasis (gallstones) or dense biliary sludge. The surrounding liver parenchyma appears homogeneous with normal echotexture. These images are captured using a curvilinear probe, as indicated by the sector-shaped field of view and the anatomical orientation marker showing placement in the subcostal region. The presence of these findings is clinically significant for diagnosing gallbladder pathology and distinguishing between biliary sludge and formed calculi based on the intensity of the acoustic shadow.

Ultrasound examination of the gallbladder using grayscale B-mode ultrasonography (transabdominal approach) demonstrates two echogenic foci within the gallbladder lumen. Both features are dependent on the gallbladder, implying intraluminal calculi rather than extrinsic objects. Each lesion casts a posterior acoustic shadow, a hallmark of gallstones, and their appearance distinguishes calcified cholesterol stones from gallbladder polyps, which typically lack shadowing. The stones measure over 2 millimeters in diameter, consistent with cholelithiasis and enabling reliable detection by ultrasound. The gallbladder wall appears without significant thickening, and there is no overt pericholecystic fluid evident on this image, arguing against acute cholecystitis at the time of imaging. The study highlights the classic sonographic criteria for gallstone disease: echogenic mobile calculi with clean shadowing, gravity-dependent location, and recognition of potential sludge in the gallbladder lumen. This imaging feature set supports clinical decisions regarding symptomatic biliary colic, risk stratification for complications, and surgical planning such as cholecystectomy. In differential considerations, gallbladder polyps or sludge can mimic stones; however, shadowing and mobility aid differentiation. Overall, ultrasound remains the initial modality of choice for suspected biliary pathology due to safety, accessibility, and high diagnostic yield. Correlative clinical data and laboratory tests further refine management decisions. Guiding patient-specific treatment options.