What is the management of gallbladder (cholelithiasis) polyps?

From the Guidelines

The management of gallbladder polyps should be based on their size, growth pattern, and risk factors for malignancy, with surgical consultation recommended for polyps of 15 mm or greater, and consideration of cholecystectomy for polyps 10mm or larger due to increased risk of malignancy. The size of the polyp is a significant factor in determining the risk of malignancy, with polyps smaller than 10mm having a low risk of malignancy 1. For polyps smaller than 10mm, watchful waiting with regular ultrasound surveillance is recommended, typically every 6-12 months initially. If the polyp remains stable after 2-3 years, surveillance intervals can be extended.

• The decision for surgical consultation for polyps measuring 10–14 mm may be made depending on patient factors or evidence of growth at follow-up imaging 1.
• Cholecystectomy should also be considered for smaller polyps if they show growth during surveillance, if the patient has risk factors for gallbladder cancer (such as age over 50, primary sclerosing cholangitis, or Indian ethnicity), or if the polyp is symptomatic.
• True polyps must be distinguished from pseudopolyps (cholesterol polyps, adenomyomatosis, or inflammatory polyps), which have minimal malignant potential.
• No medications effectively treat gallbladder polyps, and dietary modifications have not been proven to affect polyp growth or regression.
• The management approach balances the risk of malignancy against surgical risks, with the goal of preventing gallbladder cancer while avoiding unnecessary surgery, and patient selection for surgery is multifactorial, requiring shared decision-making, and must take into account patient health status as well as risk profiles of imaging findings 1.

From the Research

Diagnosis and Classification of Gallbladder Polyps

• Gallbladder polyps can be divided into neoplastic (true) polyps and nonneoplastic polyps (pseudopolyps) 2
• Pseudopolyps are most commonly cholesterol polyps but also include focal adenomyomatosis and inflammatory polyps with no malignant potential 2
• Neoplastic polyps, however, can be benign or malignant, with benign polyps being most commonly adenomas, and malignant polyps usually being adenocarcinoma 2

Management of Gallbladder Polyps

• The current guidelines recommend cholecystectomy for GB polyps ≥ 10 mm in size as well as suboptimal sized GB polyps (6-9 mm) with other risk factors, including age >50, sessile, and symptoms 2
• For GBPs <1 cm, surveillance may not be needed for GBPs <5 mm, and for GBPs between 5 and 10 mm, two scans at six monthly intervals is suggested 3
• Cholecystectomy is advised where size increases to >10 mm 3
• In patients over 50 years of age with co-existent cholelithiasis and GP exceeding 10 mm, surgical treatment should be undertaken due to the risk of malignancy 4

Risk Factors for Malignancy

• The risk of malignancy is high in patients over 50 years old who have single polyps with diameters > 10 mm 5
• Malignant GBPs ≥1 cm, <1 cm and <5 mm constituted 8.5,1.2 and 0% of GBPs, respectively 3
• The mean age of patients with adenocarcinoma was 60 years (55-74), all of whom had solitary polyps 4

Imaging Modalities

• Transabdominal ultrasonography is the main radiological modality used for diagnosing and surveilling GB polyps 2
• The sensitivity of USG was 84.6% for polyps with diameters > 10 mm, however it was only 66% in polyps with diameters < 10 mm 5
• Alternative imaging modalities, such as endoscopic ultrasound, are being further evaluated due to the difficulty in diagnosing GB polyps before surgery 2