Why do gallbladder polyps without cholecystitis on ultrasound findings cause pain?

Why Gallbladder Polyps Without Cholecystitis Cause Pain

Gallbladder polyps themselves are typically asymptomatic and do not directly cause pain—when pain occurs in patients with incidentally detected polyps, it is almost always due to coexisting pathology such as biliary colic from gallstones, functional gallbladder disorders, or other unrelated abdominal conditions. 1

The Disconnect Between Polyps and Pain

The medical literature consistently demonstrates that gallbladder polyps are predominantly incidental findings discovered during imaging for other reasons, not the primary source of symptoms:

• Most polyps are discovered incidentally during ultrasound examinations performed for unrelated reasons or during evaluation of abdominal pain that ultimately has another etiology 2, 3
• In surgical series, the vast majority of patients with polyps have coexisting gallbladder pathology (chronic cholecystitis, gallstones) that better explains their symptoms 4
• Cholesterol polyps—the most common type of gallbladder polyp—are pseudotumors with no known mechanism to cause pain and have no malignant potential 3, 4

When Pain Coexists: Identifying the True Culprit

When patients with gallbladder polyps present with pain, a systematic approach is needed to identify the actual pain source:

Coexisting Gallstones (Most Common)

• Gallstones are ubiquitous and frequently coexist with polyps 1
• The pain pattern is typically biliary colic—episodic right upper quadrant pain that may radiate to the back or shoulder 4
• Gallstones cause pain through cystic duct obstruction, not the polyp itself 5

Chronic Cholecystitis Without Acute Inflammation

• Pathologic studies show that even when ultrasound shows no acute cholecystitis, chronic cholecystitis is frequently present on surgical specimens 4
• This chronic inflammation can cause dyspeptic symptoms and vague abdominal discomfort
• The ultrasound finding of "no cholecystitis" refers to absence of acute inflammatory changes (wall thickening >3-4mm, pericholecystic fluid, sonographic Murphy's sign), not chronic changes 1

Functional Gallbladder Disorders

• Some patients have biliary-type pain without stones or acute inflammation due to gallbladder dysmotility
• These patients may coincidentally have polyps discovered during workup

Critical Clinical Pitfall

The most important pitfall is attributing pain to an incidental polyp and performing cholecystectomy for the wrong indication:

• In one surgical series, 27% of patients who underwent cholecystectomy for presumed polyps had no polyp identified on final pathology, yet many had other gallbladder pathology explaining their symptoms 6
• Another study showed that 61-69% of polyps seen on ultrasound are not found at subsequent cholecystectomy 1
• Patients with "dyseptic symptoms but no painful episodes consistent with biliary colic should be managed conservatively" rather than surgically 4

The Evidence on Symptomatic Polyps

The guidelines acknowledge this diagnostic dilemma:

• Symptomatic polyps are an indication for cholecystectomy 3, 7, 4, but this recommendation assumes the polyp is truly the pain source
• The Society of Radiologists in Ultrasound notes that "cholecystectomy performed in acute illness, such as cholecystitis, is the greatest predictor of increased morbidity when compared with elective surgery for biliary colic or asymptomatic polyps" 1—implying that polyps themselves are typically asymptomatic
• One study specifically noted that "patients who have biliary pain and small gallbladder polyps without gallstones present a difficult management decision" 7

Practical Approach to Pain in Patients with Polyps

When a patient with a gallbladder polyp presents with pain:

1. Characterize the pain pattern carefully—true biliary colic is episodic, postprandial, and severe 4
2. Look for alternative explanations on imaging—gallstones (even small ones), gallbladder wall thickening suggesting chronic cholecystitis, or other abdominal pathology 4, 6
3. Consider that the polyp is an incidental finding unless it has high-risk features (>10mm, sessile, vascular) 8, 2
4. If pain is vague or atypical, manage conservatively with observation rather than immediate surgery 4

Bottom Line

Gallbladder polyps without cholecystitis on ultrasound do not have a physiologic mechanism to produce pain. When pain occurs in these patients, it is nearly always due to coexisting pathology (most commonly gallstones or chronic cholecystitis not visible on ultrasound) or unrelated conditions. The polyp is typically an incidental finding that should be managed based on its malignancy risk profile, not attributed as the pain source without compelling evidence.