What is the treatment for gallbladder (cholecystic) polyps?

From the Guidelines

The treatment of gallbladder polyps should be based on their size, with polyps 15 mm or larger requiring surgical consultation, and those with rapid growth of 4 mm or more within 1 year also necessitating surgical evaluation. When considering the management of gallbladder polyps, it's crucial to prioritize the risk of malignancy and the potential for rapid growth, as highlighted in the study by the Society of Radiologists in Ultrasound consensus conference recommendations 1. This approach ensures that patients receive timely and appropriate care to minimize morbidity, mortality, and improve quality of life.

Key Considerations for Gallbladder Polyp Management

• For polyps smaller than 10mm without symptoms, watchful waiting with regular ultrasound monitoring every 6-12 months is typically recommended.
• Polyps larger than 10mm, those that grow during monitoring, or those causing symptoms like pain, should be considered for cholecystectomy (surgical removal of the gallbladder) due to the increased risk of malignancy.
• The risk of malignancy increases with polyp size, and polyps over 10mm are associated with a higher risk of gallbladder cancer (GBC), as noted in the EASL clinical practice guidelines on sclerosing cholangitis 1.
• Patients with primary sclerosing cholangitis (PSC) are at an increased risk of gallbladder carcinoma, and cholecystectomy is recommended for those with gallbladder polyps greater than or equal to 8mm in size or smaller polyps that are growing in size.

Surgical Considerations

• Cholecystectomy is usually performed laparoscopically, requiring 3-4 small incisions, and allows patients to return home within 24 hours.
• Recovery from the procedure typically takes about 1-2 weeks.
• After gallbladder removal, most patients adapt well with minimal dietary changes, though some may experience looser stools initially.
• Regular follow-up is important, especially for patients with risk factors like PSC or a family history of gallbladder cancer, as emphasized in the study by van Erp et al, which found that rapid polyp growth can lead to malignancy 1.

From the Research

Treatment of Gallbladder Polyps

• The primary investigation of polypoid lesions of the gallbladder should be with abdominal ultrasound 2.
• Cholecystectomy is recommended in patients with polypoid lesions of the gallbladder measuring 10 mm or more, providing the patient is fit for, and accepts, surgery 2, 3, 4, 5.
• Cholecystectomy is suggested for patients with a polypoid lesion and symptoms potentially attributable to the gallbladder if no alternative cause for the patient's symptoms is demonstrated and the patient is fit for, and accepts, surgery 2.
• If the patient has a 6-9 mm polypoid lesion of the gallbladder and one or more risk factors for malignancy, cholecystectomy is recommended if the patient is fit for, and accepts, surgery 2, 3, 5.
• Risk factors for malignancy include age more than 60 years, history of primary sclerosing cholangitis (PSC), Asian ethnicity, sessile polypoid lesion (including focal gallbladder wall thickening > 4 mm) 2, and Indian ethnicity 5.

Follow-up of Gallbladder Polyps

• If the patient has either no risk factors for malignancy and a gallbladder polypoid lesion of 6-9 mm, or risk factors for malignancy and a gallbladder polypoid lesion 5 mm or less, follow-up ultrasound of the gallbladder is recommended at 6 months, 1 year, and 2 years 2.
• If the patient has no risk factors for malignancy, and a gallbladder polypoid lesion of 5 mm or less, follow-up is not required 2.
• If during follow-up the gallbladder polypoid lesion grows to 10 mm, then cholecystectomy is advised 2, 4.
• If the gallbladder polypoid lesion disappears during follow-up, then monitoring can be discontinued 2.

Alternative Imaging Modalities

• Alternative imaging modalities, such as contrast-enhanced and endoscopic ultrasound, may be useful to aid decision-making in difficult cases, but their routine use is not recommended presently 2.
• Endoscopic ultrasound is being further evaluated as an alternative imaging modality for diagnosing GB polyps 3.