[The classification of biliary calculi and the clinico-therapeutic implications]

A new classification of gallstones is reported, which has interesting implications for diagnostic and therapeutic purposes. Gallstones have been divided according to "type" into the following categories: cholesterol (single, multiple), mixed, black pigment, brown pigment, combination and composite. In addition, gallstones primarily formed within the gallbladder have been distinguished from those initially formed in the common duct (before and after surgery) and within the intrahepatic ducts. Stone type and composition have been related to symptoms, on the basis of a new view, according to which gallstones are not a unique entity, but a heterogeneous disease including different entities, each of which has its own pathogenesis, clinical manifestations, biological behaviour and also deserves a different treatment. The proper treatment should be appropriate to the individual and his stones. Therapeutic guide-lines are suggested for each type of stones, in particular for stones complicated by cholangitis, pancreatitis, or for common duct stones concomitantly found with gallbladder stones. For the last group, techniques and therapeutic options preserving the function of the sphincter of Oddi are recommended. Suggestions are also reported concerning the treatment of various types of hepatolithiasis: primary, i.e. associated with cystic intrahepatic bile duct dilatation; post-surgical, i.e. occurring cranially to a biliary enteric anastomosis: secondary, i.e. associated with concomitant gallbladder and common duct stones.