What is the recommended treatment for a gallbladder (cholecystic) polyp, especially one larger than 10 mm?

Management of Gallbladder Polyps

Cholecystectomy is strongly recommended for gallbladder polyps ≥10 mm in size due to the significant risk of malignancy. 1, 2

Size-Based Management Algorithm

Polyps ≥10 mm

• Cholecystectomy is indicated regardless of symptoms if the patient is fit for surgery
• Rationale: High risk of malignancy (up to 20.1% of surgically removed polyps may be malignant) 3
• Laparoscopic cholecystectomy is the preferred approach in most cases 1

Polyps 6-9 mm

• Cholecystectomy recommended if ANY risk factors are present:
  • Age >60 years
  • Primary sclerosing cholangitis (PSC)
  • Asian ethnicity
  • Sessile polyp (including focal wall thickening >4 mm)
  • Rapid growth (≥2 mm within follow-up period)
• Follow-up with ultrasound if no risk factors:
  • At 6 months, 1 year, and 2 years
  • Discontinue follow-up after 2 years if no growth 2

Polyps ≤5 mm

• No follow-up required if no risk factors 2
• Follow-up with ultrasound if risk factors present:
  • Every 3-6 months initially 1
• Cholecystectomy recommended for PSC patients with polyps ≥8 mm 4

Special Considerations

Symptomatic Polyps

• Cholecystectomy recommended for symptomatic polyps regardless of size if:
  • No alternative cause for symptoms is identified
  • Patient is fit for surgery 2
• Common symptoms include right quadrant abdominal pain and epigastric pain 3

High-Risk Patients

• Lower threshold for cholecystectomy in:
  • Patients with PSC (cholecystectomy recommended for polyps ≥8 mm) 4
  • Patients >50 years (32.4% malignancy rate vs. 4.7% in those <50 years) 3
  • Patients with calcified ("porcelain") gallbladder 1
  • Patients with large gallstones (>2 cm) 1

Contrast-Enhanced Ultrasound

• Consider for better characterization of polyps when standard ultrasound findings are equivocal
• Particularly useful for distinguishing true polyps from sludge 1
• For small polyps in PSC patients, contrast-enhanced ultrasound should be used; if contrast-enhancing polyp is found, cholecystectomy should be considered regardless of size 4

Follow-up Protocol

• Growth of ≥4 mm within 12 months warrants surgical consultation 1
• If polyp grows to ≥10 mm during follow-up, cholecystectomy is advised 2
• If polyp disappears during follow-up, monitoring can be discontinued 2
• Extended follow-up beyond 3 years is generally not productive 1

Pitfalls and Caveats

• Malignancy has been reported in polyps smaller than 10 mm (5% of malignant polyps were 3-5 mm, 8% were 5-10 mm) 3
• Ultrasound is the primary diagnostic tool but may have limitations in accurately measuring polyp size
• Patients with severe liver disease or decompensated cirrhosis have increased risk of complications from cholecystectomy; careful risk-benefit assessment is required 4
• Multiple small polyps (<8 mm) may spontaneously decrease in size or disappear on follow-up 4
• A cutoff of 12 mm may provide better specificity for predicting malignancy according to some studies 5

By following this evidence-based approach to gallbladder polyp management, clinicians can minimize the risk of gallbladder cancer while avoiding unnecessary surgeries in low-risk patients.