Gastroenterology Hepatology

Gallbladder polyps

How can I be sure that the patient has gallbladder polyps?

Gallbladder polyps typically do not cause any symptoms. They are usually found incidentally after cholecystectomy or on imaging studies performed for other causes. Occasionally, when seen on imaging performed for abdominal pain, the symptoms may be similar to biliary pain.

Detached portion of the polyp may block the Hartmann's pouch or cystic duct and may cause cholecystitis. Similarly, if the detached portion of the polyp blocks the main bile duct, this may result in obstructive jaundice or pancreatitis.

Gallbladder polyps have also been associated with chronic dyspeptic abdominal pain.  

Usual constellation of clinical features

Gallbladder polyps can have various clinical features. The asymptomatic patient is the most common. Other presentations include biliary pain (less in intensity than that caused by gallstones), dyspepsia, obstructive jaundice (scleral icterus, dark urine, acholic stools), cholangitis (abdominal pain, fever, jaundice), and pancreatitis (abdominal pain, elevations of amylase and/or lipase).

A tabular or chart listing of features and signs and symptoms

There are no pathognomonic features of gallbladder polyps. Rather, most of them are found incidentally after a cholecystectomy or on imaging performed for some other indication.

Less common clinical presentations are biliary pain when polyps prolapse into the Hartmann's pouch, with decrease in intensity of pain after spontaneous reduction. Occasionally, patients may present with cholecystitis if the detached portion of the polyp blocks the cystic duct.

Most commonly, patients have nonspecific dyspeptic symptoms. Other presentations as mentioned above could be related to the polyp blocking the main bile duct, resulting in jaundice or pancreatitis. (See Table I.)

Table I. Differential diagnosis of gallbladder polyps
  Gallbladder polyps Gallstones Cholecystitis Spasm of SO Ampullary tumor Biliary stricture Nonspecific dyspepsia
Symptoms Noneor dyspepsia orbiliary type pain Noneorbiliary colic orjaundice if bile duct obstruction Right upper quadrant pain,biliary colic usually lasting >6 hours, nausea, vomiting, fever Abdominal pain Asymptomatic, weight loss, jaundice, or abdominal pain Related to cause. Jaundice, fever with chills Nonspecific abdominal discomfort
Signs None orAbdominal tenderness None;abdominal tenderness,jaundice ifbile duct obstruction Fever, right subcostal tenderness on inspiration (Murphy's sign),mild jaundice Abdominal tenderness, abnormal liver chemistries or amylase/lipase None orjaundice orabdominal tenderness if biliary or pancreatic duct obstruction Jaundice, stigmata of disease contributing of stricture None or related to the underlying cause
Other features Jaundice or pancreatitis if polyp blocks the main bile duct Obstructive jaundice. Intermittent elevation of liver chemistries if choledocho-lithiasis Leukocytosis, abnormal liver chemistries Abnormal liver chemistries or elevated amylase/lipase. Bile duct dilation Cholestasis, pancreatitis, weight loss Cholestasis, cholangitis  

How can I confirm the diagnosis?

Currently, none of the available tests can predict the polyp type or histology accurately, but a combination of features seen on transabdominal ultrasound, CT scan, and EUS can provide the information needed to further manage a patient with gallbladder polyps. A transabdominal ultrasound is a safe and noninvasive way to diagnose gallbladder polyps that appear as echogenic foci.

Endoscopic ultrasound is a sensitive and specific method for diagnosing gallbladder polyps. Endoscopic sonographic scoring system that incorporates the size, number, shape, and echogenicity of polyps may help in predicting their neoplastic potential.

Other tests that can be useful are oral cholecystography, which, however, has largely fallen out of favor for the ultrasound, which is more sensitive and specific. Polyps usually appear as immobile filling defects on a cholecystogram.

CT scan can also help in diagnosing gallbladder polyps especially in patients with gallbladder cancer because it can also help in staging disease.

What other diseases, conditions, or complications should I look for in patients with gallbladder polyps?

Most gallbladder polyps are benign. However, there is a risk of neoplastic progression, especially in larger polyps or polyps with uncertain character. The incidence of carcinoma has been said to be as high as 100% in polyps larger than 2 cm.

Gallbladder polyps may detach and block the Hartmann's pouch (causing biliary pain), cystic duct (cholecystitis), main bile duct, or ampulla (obstructive jaundice or pancreatitis). Neoplastic progression to carcinoma is commonly seen with larger polyps, especially those more than 10 mm. (See Table II.)

Table II. Complications of gallbladder polyps
1 Malignant transformation
2 Frequent biliary pain
3 Acute cholecystitis
4 Obstructive jaundice
5 Pancreatitis

What is the right therapy for the patient with gallbladder polyps?

Effective treatment options

Management options for gallbladder polyps include surveillance or cholecystectomy, which should be considered in patients who have symptoms suggestive of biliary origin as well as in those who have polyps larger than 10 mm.

  • Patients with larger polyps (>10 mm) or those with symptoms should be considered for a cholecystectomy.

  • Patients with gallstones or primary sclerosing cholangitis (PSC) should be considered for surgery irrespective of size because of the high incidence of malignant transformation of polyps associated with these conditions.

  • Other options including surveillance with imaging and/or endoscopic ultrasound every 6 to 12 months can be considered in patients who have smaller polyps (<10 mm in size) or those with larger polyps but are considered to be high-risk for surgery.

  • Lifestyle modifications do not have much of a role in either polyp formation or their malignant transformation.

What is the most effective initial therapy?

The most effective therapy is cholecystectomy in symptomatic patients or in those with polyps larger than 10 mm in size.

Listing of usual initial therapeutic options, including guidelines for use, along with expected result of therapy.

Cholecystectomy is recommended for polyps larger than 10 mm in size or polyps that are present in a patient with gallstones, PSC, or those patients who are symptomatic.

For patients who are high risk for surgical intervention and have polyps larger than 10 mm, periodic surveillance every 6 to 12 months with transabdominal or endoscopic ultrasound is acceptable, with the caveat that these patients may need referral for surgery if there is any change in the character of the polyp.

A listing of a subset of second-line therapies, including guidelines for choosing and using these salvage therapies

  • Side effects or complications related to cholecystectomy are those that would be associated with surgery and the use of anesthesia.

  • Complications related to anesthesia include cardiovascular or pulmonary compromise.

  • Complications related to surgery include those that occur intra-operatively and may require conversion to laparotomy. These include injury to blood vessels, bile duct, liver, bowel, and adjacent structures.

  • Post-operative complications include injury to the bile duct, bile leaks, ischemia, retained bile duct stones, post cholecystectomy syndrome, or even another diagnosis such as sphincter of Oddi dysfunction.

Listing of these, including any guidelines for monitoring side effects.

N/A

How should I monitor the patient with gallbladder polyps?

Monitoring includes the following:

1. Malignant transformation. Intense surveillance by imaging or EUS, especially in polyps larger than 10 mm and referral for cholecystectomy if there is a change in size or character of the polyp.

2. Frequent biliary pain. Evaluate change in symptoms due to detachment of polyp, resulting in obstruction of the biliary tree or development of systemic signs that may suggest a malignancy.

3. Acute cholecystitis. Right upper quadrant pain, elevation of white blood count, fever.

4. Obstructive jaundice. Elevation of liver tests in a cholestatic pattern along with imaging to evaluate for biliary ductal dilation.

5. Pancreatitis. Abdominal pain along with elevation in serum lipase and/or amylase and/or imaging showing inflammation of the pancreas.

Progress of the stage of the disease is monitored with either a transabdominal or endoscopic ultrasound performed periodically, based on the size of the polyp and patient characteristics. Surveillance intervals can be increased if polyps, especially those smaller than 10 mm, remain stable for over a period of time.

Because of the benign nature of most gallbladder polyps, a wait-and-watch approach is reasonable in the case of small polyps.

The main risk of gallbladder polyps is malignant transformation. Since gallbladder cancer carries a dismal prognosis with resection being the only definitive cure, surveillance is warranted in polyps with larger size in those patients who are at high risk for surgery.

Polyps of any size if associated with gallstones, PSC, or if a patient is symptomatic, warrant a cholecystectomy. Patients who have dyspeptic symptoms not attributable to biliary origin should be managed symptomatically.

For all other patients, size of the polyp can help to determine the monitoring intervals or therapeutic options.

  • Polyps smaller than 5 mm. Usually benign cholesterol lesions. Follow up ultrasound at 6 months and 1 year is recommended in such patients. Further follow-up is not recommended if there is no change in the size and character of the polyp.

  • Polyps between 5 and 10 mm. Could be cholesterol polyps, an adenoma, or carcinoma. Multiple or pedunculated polyps are usually cholesterol polyps, whereas solitary or sessile polyps are more likely to be neoplastic. It is recommended that these polyps be followed with ultrasound at 3 months, 6 months, and then yearly, if stable.

  • Polyps between 10 and 20 mm.Usually considered to be malignant, and patients with such polyps should be referred for cholecystectomy with full thickness dissection. In patients who are high risk for surgery, intense surveillance with imaging or EUS should be performed. Surgery is recommended in such patients if there is a change in size or character of the polyp.

  • Polyps larger than 18 to 20 mm in size. Malignant and should be resected. Patients with such polyps should also undergo imaging and EUS to exclude metastatic disease, as these polyps usually represent advanced disease. Extended cholecystectomy with lymph node dissection and partial hepatic resection in the gallbladder bed is recommended if malignancy is proved.

What's the evidence?

Corwin, MT, Siewert, B, Sheiman, RG, Kane, RA. "Incidentally detected gallbladder polyps: is follow-up necessary?—Long-term clinical and US analysis of 346 patients". Radiology. vol. 258. 2011. pp. 277.

(Highlights the low likelihood of GB malignancy in small polyps.)

Kane, CF, Brown, CH, Hoerr, SO. "Papilloma of the gallbladder; report of eight cases". Am J Surg. vol. 83. 1952. pp. 161.

(Eight patients with papillomas out of 2000 cholecystectomies performed at their center and none of the patients had symptoms suggestive of papilloma, indicating that papillomas typically do not cause symptoms.)

Kmiot, WA, Perry, EP, Donovan, IA. "Cholesterolosis in patients with chronic acalculous biliary pain". Br J Surg. vol. 81. 1994. pp. 112.

(A majority of patients with cholesterolosis improved after surgery compared with those with only chronic cholecystitis, indicating that cholesterolosis may cause acalculous biliary pain, and these patients may improve after surgery.)

Razumilava, N, Gores, GJ, Lindor, KD. "Cancer Surveillance in patients with primary sclerosing cholangitis". Hepatology. vol. 54. 2011. pp. 1842.

(Updated recommendations regarding cancer surveillance in patients with PSC, including discussions for imaging and tumor markers for surveillance.)

Eaton, JE, Thackeray, EW, Lindor, KD. "Likelihood of malignancy in gallbladder polyps and outcomes following cholecystectomy in primary sclerosing cholangitis". Am J Gastroenterol. vol. 107. 2012. pp. 431.

(Retrospective study of patients with PSC undergoing cholecystectomy, noting ~40% had early complications of surgery; suggests considering observing small polyps given surgical morbidity.)

Takii, Y, Shirai, Y, Kanehara, H, Hatakeyama, K. "Obstructive jaundice caused by a cholesterol polyp of the gallbladder: report of a case". Surg Today. vol. 24. 1994. pp. 1104.

(This article reported a case of obstructive jaundice, wherein intraoperative cholangioscopy revealed an impacted cholesterol polyp.)

Parrilla Patricio, P, García Olmo, D, Pellicer Franco, E. "Gallbladder cholesterolosis: an aetiological factor in acute pancreatitis of uncertain origin". J Br J Surg. vol. 77. 1990. pp. 735.

(Authors investigated several cases of cholesterolosis without biliary lithiasis and found several patients with unexplained recurrent attacks of pancreatitis that disappeared after cholecystectomy.)

Choi, WB, Lee, SK, Kim, MH. "A new strategy to predict the neoplastic polyps of the gallbladder based on a scoring system using EUS". Gastrointest Endosc. vol. 52. 2000. pp. 372-9.

(Authors introduced a new strategy to identify patients with polyps who were at risk of neoplasia when polyps were between 5 and 15 mm.)

Ishikawa, O, Ohhigashi, H, Imaoka, S. "The difference in malignancy between pedunculated and sessile polypoid lesions of the gallbladder". Am J Gastroenterol. vol. 84. 1989. pp. 1386.

(Study puts forth the importance of size in determining the risk of neoplastic progression.)

Boulton, R, Adams, D. "Gallbladder polyps: when to wait and when to act". Lancet. vol. 349. 1997. pp. 817-18.

(Paper discusses the uncertain nature of polyps and when to operate on patients with polyps. They advocate that a wait-and-watch policy should be followed very cautiously because of uncertain nature of polyps.

Koga, A, Watanabe, K, Fukuyama, T. "Diagnosis and operative indications for polypoid lesions of the gallbladder". Arch Surg. vol. 123. 1988. pp. 26.

(Authors stress the importance of size when following up patients with gallbladder polyps and mention that malignancy should be considered when polyp size is more than 10 mm.)

Kubota, K, Bandai, Y, Noie, T. "How should polypoid lesions of the gallbladder be treated in the era of laparoscopic cholecystectomy?". Surgery. vol. 117. 1995. pp. 481.

(Authors recommend that polyps less than 18 mm be considered high risk for cancer and should be resected, and advocate that those that are more than 18 mm be treated with partial liver resection and lymph node dissection along with cholecystectomy.)

Feldman, M, Friedman, LS, Brandt, LJ. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. Saunders.

(Types of polyps and their clinical features and management.)

**The original author for this chapter was Mihir S. Wagh . The chapter was revised by Dr. Bruce R. Bacon.

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