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Gallstones contain chiefly cholesterol and/or bile pigment, with variable calcium salts and an organic matrix. They are mixtures with different predominant components, not one compound with a universal formula. The period word cholesterin denotes cholesterol.

Cholesterol-rich stones contain crystalline cholesterol, often with a smaller pigmented nucleus and layers of other material. Mixed stones combine cholesterol, pigment, calcium salts and an organic matrix including mucin. Pigment stones contain much less cholesterol; a major constituent is calcium bilirubinate, related to the bile pigment bilirubin. Minor inorganic constituents can include calcium carbonate and calcium phosphate. Not every visibly dark stone has the same composition, and no fixed percentage follows from the question.^[ref]

The useful modern subdivision of pigment stones is into black and brown types. Black stones commonly contain polymerised pigment with calcium salts; brown stones include calcium bilirubinate and calcium salts of fatty acids, particularly in infected stagnant duct bile. These refinements explain why neither “all stones are cholesterol” nor “all stones are lime salts” is adequate.^[ref]

Chemical examination should distinguish the fractions rather than infer them merely from the external colour. Cholesterol can be extracted with a suitable organic solvent and recognised in recrystallised material; microscopy can show characteristic plate-like crystals. A mineral residue after removal or destruction of organic matter indicates an inorganic fraction, but residue alone cannot identify a particular salt. Layering, facets and colour describe growth and packing and are not chemical analyses. In particular, calcium bilirubinate is not interchangeable with calcium carbonate, and cholesterol is not a bile salt.

The signs depend on the obstructed site: a stone in the cystic duct, the common bile duct and the outlet shared with the pancreatic duct can produce different syndromes. “An impacted gallstone” is not enough anatomical information to choose a treatment.

A typical pain pattern is severe upper abdominal pain, often in the right upper quadrant or epigastrium, sometimes radiating to the back or shoulder, with nausea and vomiting. Despite the term “colic”, the pain can remain steady during an attack. Persistent focal tenderness with fever suggests acute cholecystitis rather than an uncomplicated transient obstruction. Cystic-duct obstruction does not necessarily obstruct hepatic bile flow and therefore need not produce jaundice.

A stone obstructing the common bile duct can produce jaundice, dark urine and pale stools. Fever or rigors with jaundice and biliary pain raises concern for acute cholangitis, while shock or altered awareness indicates serious illness. Obstruction at the distal outflow can precipitate acute pancreatitis, often with prominent pain radiating to the back and vomiting. These are patterns to investigate, not findings supplied by the examination; absence of a full classical combination does not exclude dangerous obstruction.^[ref]

An 1866 clinician would try to establish the pain's origin, look for jaundice, observe the urine and stools, relieve severe pain, support fluid intake and watch for persistent obstruction or inflammation. Warm external applications and an opiate were among the symptomatic measures of the period. Passage of a recovered stone could strengthen the diagnosis, but failure to find one in the stool did not disprove it, and temporary relief did not demonstrate duct clearance. Neither a purgative nor an asserted stone-dissolving mixture could be assumed to free an impacted duct. These are reconstructions of the diagnostic and palliative aims available before modern duct imaging and endoscopic treatment, not a current management recipe.

Modern correction: investigate promptly and relieve consequential obstruction, rather than treating the pain alone. Obtain appropriate examination, liver function tests and ultrasonography. If suspicion of common-duct stones remains because of abnormal tests or duct dilatation despite no stone being shown, magnetic resonance cholangiopancreatography can clarify the ducts; endoscopic ultrasonography is an additional option when needed. Evaluate for acute pancreatitis and other causes of an acute abdomen. Relief of pain, fluid support and treatment of associated illness proceed alongside investigation.^[ref]

Symptomatic gallbladder stones generally lead to consideration of laparoscopic cholecystectomy; early surgery is recommended for suitable acute cholecystitis. Common-duct stones require duct clearance, endoscopically or surgically as appropriate.^[ref] Acute cholangitis requires urgent treatment of infection and biliary decompression. Antibiotics and resuscitation do not remove an obstructing stone. Endoscopic drainage is generally preferred when feasible; stone removal may accompany it if the person's condition permits, while an unstable person may need decompression before a more extensive procedure.^[ref] This is why prolonged pain with jaundice or fever cannot safely be managed merely by repeating historical analgesic mixtures.