From the Guidelines
Gallbladder polyps larger than 15mm should be referred for surgical consultation due to the increased risk of neoplasia, as recommended by the Society of Radiologists in Ultrasound consensus conference 1.
Key Considerations
- Polyp size is a significant factor in determining the risk of malignancy, with larger polyps having a higher risk of neoplasia 1.
- For polyps between 10-14mm, the decision for surgical consultation should be made on a case-by-case basis, taking into account patient factors and evidence of growth at follow-up imaging 1.
- Polyps smaller than 10mm have a low risk of malignancy, and the need for surgical consultation can be determined based on individual patient factors and imaging findings 1.
Management Approach
- Polyps larger than 15mm: Refer for surgical consultation due to the increased risk of neoplasia 1.
- Polyps between 10-14mm: Consider surgical consultation based on patient factors and evidence of growth at follow-up imaging 1.
- Polyps between 6-10mm: Follow-up ultrasound is recommended at 6,12, and 24 months to monitor for growth 1.
- Polyps smaller than 6mm: A single follow-up ultrasound at 12 months is generally recommended, and if stable, no further imaging is needed 1.
Risk Factors
- Age over 50
- Concurrent gallstones
- Primary sclerosing cholangitis
- Indian ethnicity
- Rapid polyp growth (more than 2mm in 6 months)
- Sessile polyps or those with irregular borders
Patient Counseling
- Patients should be counseled about symptoms requiring urgent evaluation, including jaundice, right upper quadrant pain, or unexplained weight loss.
- No medications effectively treat gallbladder polyps, and dietary modifications have not been proven beneficial.
- The management approach balances the low overall risk of malignancy against the morbidity of unnecessary surgery, as most polyps are benign cholesterol deposits or adenomyomas that remain stable over time 1.
From the Research
Gallbladder Polyp Management
- The management of gallbladder polyps is controversial, with some studies suggesting that cholecystectomy is recommended for polyps equal to or greater than 10 mm due to their malignant potential 2, 3.
- However, other studies have found that the majority of lesions appear to be pseudopolyps with no malignant potential, questioning the usefulness of current guidelines for management of suspected gallbladder polyps 2.
- The prevalence of true gallbladder polyps was found to be much lower than reported in literature, with 97% of patients having non-neoplastic or not identifiable lesions in the gallbladder after cholecystectomy 2.
Indications for Cholecystectomy
- Cholecystectomy is indicated for neoplastic gallbladder polyps (NGP) larger than 10mm, or symptomatic, or larger than 6mm with associated risk factors for cancer (age over 50, sessile polyp, Indian ethnicity, or patient with primary sclerosing cholangitis) 3.
- A reasonable cutoff for considering a malignant polyp may be 12 mm, with gallbladder polyps with 10-11 mm in asymptomatic young patients (less than 50 years old) having a low risk of malignancy 4.
- Simple sonographic surveillance is recommended for at least five years for NGP, with cholecystectomy indicated if the NGP increases in size by more than 2mm 3.
Diagnostic Accuracy
- The sensitivity of ultrasonography (USG) in detecting polyps was found to be 64.7% 5.
- Abdominal sonography is the first line study for diagnosis and follow-up for NGP, with comprehensive imaging workup recommended to search for liver extension if malignant NGP is suspected 3.
Treatment Outcomes
- The pathological result of many patients who undergo cholecystectomy due to gallbladder polyps is pseudopolyp or adenoma, with no carcinoma observed in some studies 5.
- Laparoscopic cholecystectomy is possible, but conversion to laparotomy should be preferred if the risk of intra-operative gallbladder perforation is high to avoid potential intra-abdominal tumoral dissemination 3.