What is the next step for a patient with a slightly over-distended gallbladder (gallbladder) showing multiple polypoid structures, likely cholesterol polyps, and fatty infiltration of the liver (hepatic steatosis), with a normal pancreas?

From the Guidelines

The next step for a patient with gallbladder polyps and fatty liver on ultrasound should be observation with a follow-up ultrasound in 6-12 months to monitor the polyps, particularly if they are smaller than 10mm, as the risk of malignancy is extremely low in polyps of this size 1.

Key Considerations

• The size of the polyps is a critical factor in determining the risk of neoplasia, with polyps smaller than 5mm having a 0% risk of malignancy, and those smaller than 10mm having a very low risk 1.
• The recent 2022 study by the Society of Radiologists in Ultrasound consensus conference recommendations suggests that polyp size may be associated with the risk of neoplasia, and recommends surgical consultation for polyps of 15mm or greater 1.
• For polyps measuring 10-14mm, the decision for surgical consultation may be made depending on patient factors or evidence of growth at follow-up imaging 1.
• Lifestyle modifications to address fatty liver infiltration, such as weight loss, limiting alcohol consumption, increasing physical activity, and following a balanced diet, are also recommended.

Surveillance and Monitoring

• Regular follow-up ultrasounds are necessary to monitor the size and growth of the polyps, as well as to assess for any changes in the gallbladder or surrounding tissues.
• The patient should be evaluated for metabolic conditions associated with fatty liver, such as diabetes and dyslipidemia, and managed accordingly.

Surgical Consultation

• Surgical consultation for possible cholecystectomy should be considered if any polyps are larger than 10mm, are rapidly growing, or if the patient has symptoms like right upper quadrant pain, nausea, or vomiting, due to the increased risk of gallbladder cancer 1.

From the FDA Drug Label

Fenofibrate, like clofibrate and gemfibrozil, may increase cholesterol excretion into the bile, leading to cholelithiasis. If cholelithiasis is suspected, gallbladder studies are indicated. Fenofibrate tablets therapy should be discontinued if gallstones are found.

The next step is to discontinue fenofibrate therapy since gallbladder ultrasound shows multiple polypoid structures attached to the gallbladder wall, which are most likely cholesterol polyps, indicating a possible increased risk of cholelithiasis 2.

From the Research

Next Steps for Gallbladder Polyp Evaluation

The patient's gallbladder ultrasound shows multiple polypoid structures attached to the gallbladder wall, which are most likely cholesterol polyps, and fatty infiltration of the liver. The pancreas is normal. Based on the provided studies, the next steps for evaluation can be considered as follows:

• Targeted Transabdominal Ultrasound (TAUS) and MRI: A study by 3 proposes a checklist for polyp evaluation by targeted TAUS and a flowchart for radiological work-up of gallbladder polyps. This approach may aid in diagnostic work-up for gallbladder polyps by eliminating nonneoplastic polyps.
• Ultrasound Scoring System: Research by 4 suggests the use of an ultrasound scoring system based on independent predictive parameters to distinguish adenomatous polyps from cholesterol polyps. The scoring system considers factors such as maximum size, height/width ratio, stone or sludge, vascularity, and hyperechoic spot.
• Dual-Energy CT: A study by 5 found that dual-energy computed tomography (DE-CT) can help differentiate between cholesterol and adenomatous gallbladder polyps based on mean attenuation value changes.
• Contrast-Enhanced Ultrasound (CEUS): According to 6, CEUS can assess gallbladder polyps and distinguish adenomatous polyps from cholesterol polyps by evaluating vascular stalk width and vascularity.

Key Considerations

• The size of the polyps is an important factor, with polyps larger than 1 cm being more likely to be neoplastic 3, 4.
• The presence of vascularity and the absence of hyperechoic spots are independent predictive parameters for adenomatous polyps 4.
• The use of advanced imaging techniques such as MRI, DE-CT, and CEUS can provide additional information to aid in the diagnosis and differentiation of gallbladder polyps.

Possible Diagnostic Approaches

• Use a combination of targeted TAUS, MRI, and ultrasound scoring system to evaluate the polyps and determine the likelihood of neoplasia.
• Consider DE-CT or CEUS to further differentiate between cholesterol and adenomatous polyps.
• Take into account the patient's overall clinical presentation and medical history when determining the next steps for evaluation and management.