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), a normal pancreas, and right inguinal lymphadenitis?

From the Guidelines

The next step for a patient with gallbladder polyps, fatty liver, and right inguinal lymphadenitis should be a follow-up ultrasound in 6-12 months to monitor the polyps, along with lifestyle modifications to address the fatty liver. Since the polyps are likely cholesterol polyps and are presumably small (specific size not mentioned), immediate surgical intervention is not typically warranted, as per the Society of Radiologists in Ultrasound consensus conference recommendations 1. The patient should adopt a low-fat diet, increase physical activity, maintain healthy weight, and avoid alcohol to improve fatty liver.

Key Considerations

• Regular monitoring is crucial as gallbladder polyps larger than 10mm or those that grow during follow-up carry a higher risk of malignancy and may require cholecystectomy, with the SRU consensus conference committee recommending surgical consultation for polyps of 15 mm or larger, or if a polyp has increased in size by 4 mm or more within a 12-month period 1.
• The right inguinal lymphadenitis should be evaluated separately to determine its cause, which could be related to infection or inflammation in the lower extremity or genital region.
• If the patient develops symptoms such as right upper quadrant pain, nausea, vomiting, or jaundice before the scheduled follow-up, they should seek immediate medical attention as these could indicate complications requiring more urgent intervention.

Monitoring and Follow-up

• Follow-up US at 6,12, and 24 months is recommended for polyps measuring 10–14 mm, as per the SRU consensus conference recommendations 1.
• The patient should be informed about the risks and benefits of continued monitoring versus surgical intervention, and a shared decision-making approach should be used to determine the best course of action.

From the Research

Next Steps for Gallbladder Polyps and Fatty Infiltration of the Liver

• 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 2, 3.
• Fatty liver is an independent risk factor for gallbladder polyps, with a dose-dependent relationship between the degree of fatty liver and the size of gallbladder polyps 2, 3.
• The presence of fatty liver is closely associated with gallbladder polyps, irrespective of sarcopenia and visceral obesity 2.
• Given the patient's fatty infiltration of the liver and gallbladder polyps, further evaluation and management of these conditions may be necessary, including monitoring for potential complications such as gallbladder cancer 4.
• The patient's right inguinal lymphadenitis should also be evaluated and managed separately, as it is not directly related to the gallbladder or liver conditions 5, 6.
• More research is needed to understand the pathogenesis and prognosis of fatty gallbladder disease, including steatocholecystitis, and its relationship to nonalcoholic fatty liver disease and other components of metabolic syndrome 5.