Gallbladder Polyps (GBPs) are benign lesions originating from the mucosa. Polyps are usually harmless, but cases with a diameter of more than 1 cm and adenomatous features are of clinical importance due to the possibility of developing cancer.

Gallbladder polyps are growths or lesions resembling growths (polypoid lesions) in the wall of the gallbladder. True polyps are abnormal accumulations of mucous membrane tissue that would normally be shed by the body. The main types of polypoid growths of the gallbladder include cholesterol polyp/cholesterol, cholesterol is with fibrous dysplasia of gallbladder, adenomyomatosis, hyperplastic cholecystitis, and adenocarcinoma.

Types of Gallbladder Polyps (GBPs)

Cholesterol polyps

Recent studies have shown that the majority of gallbladder polyps are benign, and 60–90% of them are cholesterol polyps. Cholesterol polyps are generally less than 10 mm. often multiple cholesterol polyps are present. They are often associated with vesicular cholesterolosis and are thought to have no malignant potential, even if three cases of carcinoma associated with cholesterolosis have been reported.[]

Inflammatory polyps

Inflammatory polyps are uncommon. They account for about 10% of gallbladder polyps and result from granulation and fibrous tissue secondary to chronic inflammation. They are typically less than 10 mm in size and are not neoplastic.[] They are local epithelial proliferation inflammatory reactions with infiltration of inflammatory cells and are often associated with chronic cholecystitis.[,]

Gallbladder adenomas

Although adenomas are benign polyps, they can exhibit premalignant behavior. These lesions are habitually pedunculated single lesions and may be associated with gallstones or chronic cholecystitis. Adenomas account for about four premalignant of gallbladder polyps and are considered neoplastic. They range in size from 5 to 20 mm and are generally solitary.[]

Adenomyomatosis

Adenomyomatosis, a noninflammatory gallbladder alteration, occurs in middle age patients, and the incidence increases with age. Originally depicted as a benign finding, it is currently identified as a precancerous lesion, and cancer cases associated with areas of adenomyomatosis have been reported [014x-6].[] Adenomyomatosis accounts for up to 25% of gallbladder polyps and usually localizes to the gallbladder fundus appearing as a solitary polyp.[,]

Causes Of Gallbladder Polyps (GBPs)

There are three main pathways in the formation of gallbladder polyps

  • Cholesterol supersaturation – Normally, bile can dissolve the amount of cholesterol excreted by the liver. But if the liver produces more cholesterol than bile can dissolve, the excess cholesterol may precipitate as crystals. Crystals are trapped in gallbladder mucus, producing gallbladder sludge. With time, the crystals may grow to form stones and occlude the ducts which ultimately produce the gallstone disease.
  • Excess bilirubin – Bilirubin, a yellow pigment derived from the breakdown of red blood cells, is secreted into bile by liver cells. Certain hematologic conditions cause the liver to make too much bilirubin through the processing of breakdown of hemoglobin. This excess bilirubin may also cause gallstone formation.
  • Gallbladder hypomotility or impaired contractility – If the gallbladder does not empty effectively, bile may become concentrated and form gallstones.
  • There’s too much bilirubin in your bile – Conditions like cirrhosis, infections, and blood disorders can cause your liver to make too much bilirubin.
  • Your gallbladder doesn’t empty all the way – This can make your bile very concentrated.
  • There’s too much cholesterol in your bile – Your body needs bile for digestion. It usually dissolves cholesterol. But when it can’t do that, the extra cholesterol might form stones.
  • Your gallbladder doesn’t empty correctly – If your gallbladder doesn’t empty completely or often enough, bile may become very concentrated, contributing to the formation of gallstones.

The Following Factors Are Known To Increase The Risk Of Gallstones

  • Age – The risk of developing gallstones increases with age, especially after you reach the age of 40.
  • Genes – If someone in your family has had gallstones.
  • Sex – Women are more likely to get gallstones than men. The female sex hormone estrogen is believed to increase the risk of gallstones.
  • Cirrhosis – A severe liver disease caused by metabolic disorders or excessive consumption of alcohol.
  • Being very overweight.
  • Losing a lot of weight in a short time – This happens a lot in very obese people who have surgery to make their stomach smaller.
  • Functional problems of the gallbladder – The organ cannot contract (squeeze bile out) properly.
  • Short bowel syndrome – A disorder that can develop after surgical removal of a large segment of the small bowel.
  • Special high – calorie liquid food.
  • Hemolysis – A disease that causes an increased breakdown of red blood cells.
  • Pregnancy.
  • Using the contraceptive pill or estrogen tablets during menopause (hormone therapy).
  • Diabetes.

Symptoms Of Gallbladder Polyps (GBPs)

The following symptoms of gallbladders polyps

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  • Sudden and rapidly intensifying pain in the upper right portion of your abdomen
  • Sudden and rapidly intensifying pain in the center of your abdomen, just below your breastbone
  • Back pain between your shoulder blades
  • Pain in your right shoulder
  • Nausea or vomiting
  • Pain in your upper belly, often on the right, just under your ribs
  • Pain in your right shoulder or back
  • An upset stomach
  • Other digestive problems, including indigestion, heartburn, and gas

See your doctor or go to the hospital if you have signs of a serious infection or inflammation

  • Belly pain that lasts several hours
  • Fever and chills
  • Yellow skin or eyes
  • Dark urine and light-colored poop

Diagnosis of Gallbladder Polyps (GBPs)

Your doctor will do a physical exam and might order tests including

  • Blood tests – These check for signs of infection or blockage and rule out other conditions.
  • Ultrasound – This makes images of the inside of your body.
  • Abdominal ultrasound – This test is the one most commonly used to look for signs of gallstones. Abdominal ultrasound involves moving a device (transducer) back and forth across your stomach area. The transducer sends signals to a computer, which creates images that show the structures in your abdomen.

In most instances, predicting histology based purely on imaging is not possible, with the possible exception of cholesterol polyps in some instances (see below), and thus features that are predictive of benign vs malignant disease should be noted. Overall size is probably the most useful indicator of malignancy, with polyps over 10 mm in diameter having a reported malignancy rate of 37-88%.

Ultrasound is the best initial imaging choice and is often able to separate cholesterol polyps from those requiring treatment. General features of gallbladder polyps are a non-shadowing polypoid ingrowth into gallbladder lumen, which is usually immobile unless there is a relatively long pedunculated component.

General features of polyps include :

  • small size
    • as cholesterol polyps are the most frequent, over 90% are <10 mm, the vast majority less than <5 mm
    • adenomas or malignant lesions tend to be larger
  • echogenicity varies with the size
    • small polyps are echogenic but non-shadowing
    • larger cholesterol polyps tend to be hypoechoic
  • morphology
    • small polyps may be adherent to the wall and smooth
    • larger lesions tend to be pedunculated and granular in outline

Adenomas, on the other hand, tend to be larger, solitary, more often sessile with internal vascularity, and of intermediate echogenicity. It is impossible to confidently distinguish an adenoma from an adenocarcinoma 6-8.

The discrepancy between the US and CT scanning

The mean values for CT scanning tended to be smaller than for the US. The discrepancies in maximum diameters between US and CT scanning were 6 ± 4 mm in the cholesterol polyp group and 2 ± 2 mm in the noncholesterol polyp group, and this difference was statistically significant.[] [] Small polypoid lesions of the gallbladder are easily detected by the US, but accuracy based solely on the US is controversial.[] The accuracy of sonography for diagnosing polypoid lesions of the gallbladder was poor.

Three-dimensional ultrasonography

Three-dimensional ultrasound (3DUS) diagnosis correlates well with two-dimensional ultrasound (2DUS) with regard to most gallbladder problems and could be sufficient as a stand-alone technique.[]

High-resolution ultrasonography

Endoscopic ultrasonography (EUS) was considered the most sensitive diagnostic modality for gallbladder polypoid lesions. However, the diagnostic accuracies of high-resolution ultrasound (HRUS) and EUS for the differential diagnosis of gallbladder polypoid lesions were comparable. []

Harmonic imaging

The quality of images in the harmonic mode is better, and the walls of the gall bladder are more distinct. The polyps were therefore more evident on harmonic images, which are more precise measurements of the polyps. In the harmonic mode, the level of artifacts generated by the body wall is reduced and contrast resolution is increased due to a reduction in noise level. The visualization of the gallbladder is improved in the harmonic mode.[]

Contrast-enhanced ultrasonography

Advances in the conventional US, such as the high-resolution US, have contributed to improved detection of polypoid gallbladder lesions. A galactose-based contrast agent was used in the US for the differential diagnosis of polypoid gallbladder lesions.[] When diffuse and branched types were considered indicative of cancer, accuracy was 85%, sensitivity 100%, and specificity 77%.

Endoscopic ultrasonography (EUS)

EUS is better than B-ultrasonography.[] EUS has gained widespread use for the diagnosis of gastrointestinal malignancies, submucosal lesions of the gastrointestinal tract, and abnormalities seen on cross-sectional imaging.[] EUS is also recommended for further examination after the conventional US because images obtained are more distinct than with the conventional US. Such images appear promising for distinguishing cholesterol polyps from other polyps, and the overall accuracy for differentiating neoplastic from non-neoplastic masses was reported as 91%.[,]

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Comparison with transabdominal ultrasonography

Transabdominal ultrasonography (US) has made the detection of gallbladder polyps easier, but the differential diagnosis of polyps less than 20 mm remains difficult. EUS markedly improve the accuracy of the differential diagnosis of gallbladder polyps and is thought to play an important role in determining the treatment strategy for gallbladder polyps.[,]

EUS scoring system

A scoring system to predict neoplastic polyps of the gallbladder has been presented.[] The total EUS score based on the coefficient of multivariate analysis was as follows: (maximum diameter in mm) + (internal echo pattern score; where heterogeneous = 4, homogeneous = 0) + (hyperechoic spot score; where presence = – 5, absence = 0). According to EUS scoring system, the sensitivity, specificity, and accuracy for the risk of neoplastic polyps with scores of 12 or higher were 78%, 83%, and 83%, respectively.[]

Magnetic resonance imaging

Magnetic resonance imaging has not been widely used to evaluate gallbladder diseases, having the disadvantages of poor spatial and contrast resolution. Among polypoid masses, malignant lesions demonstrated early and prolonged enhancements, while benign lesions showed early enhancement with subsequent washout.[][]

Positron emission tomography

It was presented a small case series of patients with gallbladder polyps that were correctly diagnosed preoperatively as benign or malignant with the use of positron emission tomography scanning with 18F-labelled deoxyglucose.[]

Intravenous cholecystography

Intravenous cholecystography is a safe technique, but gallbladder polyps do not become sufficiently opaque.[]

Transpapillary approach

Percutaneous transhepatic fine-needle aspiration and percutaneous transhepatic cholecystoscopy have been reported as precise diagnostic techniques in the evaluation of gallbladder polyps, but it is time-consuming and poorly tolerated by patients. In addition, the diagnostic accuracy of endoscopic retrograde cholangiopancreatography is not satisfactory, because this can only show a filling defect in the gallbladder without delineating the surface of polypoid lesions.[]

CT is often unable to detect small gallbladder polyps. Larger polyps will appear as soft tissue attenuation projections into the lumen of the gallbladder and will demonstrate enhancement similar to that of the rest of the gallbladder. More intense enhancement should be viewed with suspicion, as it is associated with increased vascularity in malignancy.

In 2017 joint guidelines between the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), European Association for Endoscopic Surgery and other Interventional Techniques (EAES), International Society of Digestive Surgery – European Federation (EFISDS) and European Society of Gastrointestinal Endoscopy (ESGE) were published and provide the most up to date and comprehensive guidance

  • polyp >10 mm: increased risk of malignancy, cholecystectomy recommended
  • polyp <10 mm
    • symptoms attributed to the gallbladder: cholecystectomy suggested if no other cause for the symptoms determined (polyp may be indicative of underlying occult calculus or inflammation)
    • if the patient has risk factors* for gallbladder malignancy:
      • polyp <6 mm
        • follow-up ultrasound at 6 months, then yearly for 5 years
        • an increase in size ≥2 mm: consider cholecystectomy
      • polyp >6 mm: consider cholecystectomy
    • no risk factors for gallbladder malignancy:
      • polyp <6 mm: follow-up ultrasound at 1, 3 and 5 years
      • polyp >6 mm:
        • follow up ultrasound at 6 months, then yearly for 5 years
        • an increase in size ≥2 mm: consider cholecystectomy

*risk factors: >50 years, primary sclerosing cholangitis, Indian ethnicity, sessile polyp (including focal wall thickening >4 mm)

Statistically, gallbladder polyps are common and gallbladder cancer is rare, so very few polyps progress to gallbladder cancer. There is also controversy regarding the development of gallbladder cancer and some suggest that polyps may not actually progress to cancer 10.

A previously commonly accepted strategy is:

  • ≤6 mm: no further follow up necessary 6,10
  • 6-9 mm: follow up to ensure no interval growth; follow-up interval varies from 3 to 6 months 6,9
  • ≥10 mm: surgical consultation
    • usually warrants cholecystectomy
    • if no cholecystectomy, annual follow up is justified 11

Surgery

If a polyp has grown by 2 mm or more since the last checkup, the doctor will recommend treatment. Treatment is the surgical removal of the gallbladder. This is called a cholecystectomy. There are two types:

  • Open cholecystectomy (OC) – This involves the surgeon removing the gallbladder via a large incision under the right side of the ribcage.
  • Laparoscopic cholecystectomy (LC) – This involves the surgeon removing the gallbladder via small incisions in the abdomen.
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According to researchers, lower mortality rates are associated with LC, compared with OC. However, some significant complications are more likely to result from LC. They include:

  • bile duct injuries
  • internal or external bleeding
  • abscesses under the liver

Home remedies for gallbladder polyps

Although natural treatments aren’t supported by the medical community or clinical research, many people look to natural sources for relief from benign gallbladder polyps. Some of these home remedies include:

  • warm water enemas
  • applying hot water packs externally
  • drinking pear juice or eating pears
  • drinking unrefined olive oil on an empty stomach
  • drinking beet juice or eating beets

Along with trying home remedies, some people advocate taking natural preventive steps to help reduce gallbladder polyps, including:

  • avoiding fried or fatty foods
  • avoiding high-cholesterol foods and readymade foods
  • avoiding full-fat dairy products
  • avoiding carbonated beverages
  • eating more fruits and vegetables
  • increasing intake of omega-3 fatty acids
  • increasing intake of ginger and turmeric

Consult with your doctor before you implement any home remedy or diet change. None of these home remedies are supported by medical research.

How should I monitor the patient with gallbladder polyps?

Monitoring includes the following:

  • 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.
  • 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.
  • Acute cholecystitis. Right upper quadrant pain, elevation of white blood count, fever.
  • Obstructive jaundice. Elevation of liver tests in a cholestatic pattern along with imaging to evaluate for biliary ductal dilation.
  • 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 athigh 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 are 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 are 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.

References

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