In which of the following clinical situations is pigment rather than cholesterol gallstones a more common problem?

a. Alcoholic cirrhosis

d. Hereditary spherocytosis

e. Biliary tract infection

World wide, pigment stones are the most common type of calculus found in the gallbladder. In the United States, although cholesterol calculi predominate, pigment stones constitute about 30% of all gallbladder stones. Pigment stones are characterized by a high concentration of bilirubin and a low cholesterol content. The high incidence of pigment gallstones in patients with hemolytic disorders probably results from the excessive loads of bilirubin being presented to the liver for excretion. Infection has been thought to be a key factor in the pathogenesis of pigment gallstones in that unconjugated bilirubin, produced by bacterial deconjugation, is insoluble in water, and combines with calcium in bile to produce a calcium bilirubin matrix. Specific alterations in bile acid metabolism have been proposed to explain the increased incidence of pigment gallstones found in cirrhotics. Gallstones associated with morbid obesity and rapid weight loss appear to be primarily due to the increased hepatic secretion of cholesterol leading to a cholithogenic state.