Gallbladder Polyps

Gallbladder polyps are mucosal projections into the gallbladder lumen, found in 3 to 7% of adults on ultrasound.

• Types: cholesterol polyps (60 to 70%, benign, usually multiple, under 10 mm), inflammatory polyps, adenomyomatosis, adenomas (true neoplasm, premalignant), adenocarcinoma.
• Adenomas are mostly solitary, over 10 mm.
• Risk factors for malignancy: size over 10 mm, age over 50 to 60 years, sessile morphology, solitary lesion, rapid growth (over 2 mm in 6 months), gallstones, primary sclerosing cholangitis, Indian ethnicity, Peutz-Jeghers syndrome, gallbladder wall thickening over 4 mm.
• Malignancy risk is 43% for polyps over 18 mm, and under 1% for lesions under 10 mm.

• Mostly asymptomatic, found incidentally.
• Biliary type pain, nausea in a minority (often attributable to coexisting stones or functional disease).
• Rarely jaundice, pancreatitis, or haemobilia.
• Symptoms of malignancy: weight loss, anorexia, persistent pain.

• Transabdominal ultrasound: non mobile echogenic projection without acoustic shadow (differentiates from stones); features of malignancy: size over 10 mm, sessile, vascular flow on Doppler, wall thickening.
• Endoscopic ultrasound for polyps 6 to 10 mm or atypical features: improves differentiation of cholesterol from neoplastic polyps; contrast enhanced ultrasound.
• CT/MRI for suspected malignancy or staging.
• Liver tests and CA 19-9 if suspicious.
• Assess for associated PSC, gallstones.

• Cholecystectomy is recommended for:
  • Polyp 10 mm or larger (any patient fit for surgery).
  • Polyps 6 to 9 mm with risk factors (age over 50, sessile, PSC, gallstones, growth).
  • Symptomatic polyps with exclusion of other causes.
  • Any polyp in PSC regardless of size.
• Surveillance ultrasound for polyps under 10 mm without risk factors: 6 to 12 months for polyps 6 to 9 mm for 2 years, then discontinue if stable; no follow up for under 6 mm in low risk patients.
• Cholecystectomy for increase in size of over 2 mm, or new polyp appearance.
• Laparoscopic cholecystectomy with bag extraction; open or radical resection (liver wedge resection and lymphadenectomy) if invasive cancer is suspected or confirmed on frozen section.
• Adjuvant capecitabine after radical resection of invasive disease.
• Perioperative cefazolin 2 g.