What is the recommended treatment for gallbladder (GB) polyps, especially those larger than 10 mm?

Management of Gallbladder Polyps

For polyps ≥15 mm, immediate surgical consultation for cholecystectomy is recommended; for polyps 10-14 mm, cholecystectomy is recommended in patients fit for surgery, with the decision influenced by patient risk factors or documented growth on surveillance imaging. 1, 2

Size-Based Management Algorithm

Polyps ≥15 mm

• Proceed directly to surgical consultation for cholecystectomy regardless of other features, as size ≥15 mm represents the strongest independent risk factor for neoplasia 1, 2
• Neoplastic polyps average 18.1-18.5 mm compared to 7.5-12.6 mm for benign lesions 1

Polyps 10-14 mm

• Cholecystectomy is recommended for patients fit for surgery 1, 3
• The decision may be individualized based on:
  • Patient surgical risk (morbidity 2-8%, mortality 0.2-0.7%) 2, 4
  • Presence of risk factors (age >60, PSC, Asian ethnicity, sessile morphology) 3
  • Evidence of growth ≥2 mm during surveillance 3
• If surgery is deferred, perform ultrasound surveillance at 6,12, and 24 months 4, 3

Polyps 6-9 mm

• With risk factors (age >60, PSC, Asian ethnicity, sessile morphology): cholecystectomy recommended 3, 5
• Without risk factors: ultrasound surveillance at 6,12, and 24 months; discontinue if no growth 3, 5

Polyps ≤5 mm

• No follow-up required if no risk factors present 1, 3
• Multiple studies demonstrate 0% malignancy rate in polyps <5 mm 1, 4
• 61-83% of apparent polyps ≤5 mm are not found at subsequent cholecystectomy 1

Morphology-Based Risk Stratification

Sessile (broad-based) polyps carry significantly higher malignancy risk and lower the threshold for surgical intervention 2, 4, 3

• Sessile polyps or focal wall thickening >4 mm: consider cholecystectomy even if 6-9 mm 3, 5
• Pedunculated polyps with thin stalks ("ball-on-the-wall"): extremely low risk; no follow-up needed if ≤9 mm 2, 4

Growth as a Surgical Trigger

Growth of ≥4 mm within 12 months constitutes rapid growth and warrants surgical consultation regardless of absolute size 2, 4

• Minor fluctuations of 2-3 mm are part of the natural history of benign polyps and should not trigger intervention 1, 2
• If polyp grows to ≥10 mm during surveillance, cholecystectomy is advised 3
• If polyp disappears during follow-up, monitoring can be discontinued 3

Special Population: Primary Sclerosing Cholangitis

PSC patients require a lower surgical threshold due to dramatically elevated malignancy risk (18-50% of polyps are premalignant or malignant) 1

• Cholecystectomy is recommended for polyps ≥8 mm in PSC patients (rather than the standard 10 mm threshold) 1, 2
• Smaller polyps should be characterized with contrast-enhanced ultrasound; if contrast-enhancing, consider cholecystectomy regardless of size 1
• Non-contrast-enhancing polyps should be followed with repeat ultrasound at 3-6 months 1
• Careful risk-benefit assessment required in PSC patients with advanced liver disease due to increased surgical complications 1

Advanced Imaging for Difficult Cases

When differentiation from tumefactive sludge or adenomyomatosis is challenging for polyps ≥10 mm:

• Contrast-enhanced ultrasound (CEUS) is the preferred first choice if available 2, 4, 3
• MRI is an alternative if CEUS unavailable 2, 4, 3
• Endoscopic ultrasound may provide better characterization in select cases 4, 3, 5

Critical Pitfalls to Avoid

Tumefactive sludge mimics polyps but is mobile and layering, while true polyps are fixed and non-mobile 2

• Proper patient fasting is essential for accurate ultrasound assessment 2
• 61-69% of polyps seen on ultrasound are not identified at subsequent cholecystectomy 1, 4
• Up to 83% of apparent polyps ≤5 mm are not found at surgery 1
• In one study, only 3% of patients who underwent cholecystectomy for suspected polyps had true neoplastic lesions 6

Risk Factors That Do NOT Alter Management

The following factors should not influence risk stratification or surgical decision-making:

• Coexisting gallstones 1
• Patient age alone 1
• Gender, smoking, diabetes, or obesity (relative risk increases are too small to alter absolute risk) 1

Absolute Cancer Risk Context

The absolute risk of gallbladder cancer remains low even in polyps >10 mm:

• Polyps <6 mm: 1.3 per 100,000 patients 1
• Polyps 6-10 mm: 8.7 per 100,000 patients 1
• Polyps ≥10 mm: 128 per 100,000 patients (0.4% incidence over 20 years) 1
• In a survey of approximately 3 million gallbladder ultrasounds, no documented cases of malignancy occurred in polyps <10 mm at initial detection or during follow-up 1