Gallbladder Polyps – Causes, Symptoms, Diagnosis, Treatment

pseudopolyps, inflammatory polyps,  inflammatory pseudopolyps giant pseudopolyps post-inflammatory pseudopolyps inflammatory bowel disease ulcerative colitis Crohn’s disease and “colonic polyps.

Inflammatory polyps consist of compact, non-epithelialized granulation tissue, representing a dense mixture of lymphocytes, plasma cells, and mast cells predominantly but also includes neutrophils and eosinophils, all of which are detected as infiltrating the proper lamina of ulcerated epithelium. Post-inflammatory pseudopolyps are composed of a layer of normal or slightly hyperplastic glandular epithelium, mucosa muscular, and a submucosa core of fibrovascular tissue. However, at the bowel wall, mixed forms of these types are frequently found; for example, remnant mucosa infiltrating granulation tissue or granulation tissue at the free ends of post-inflammatory polyps have been detected. The latter is due to secondary ulceration or inflammatory infiltration at the base of PPs[rx].

The gallbladder is a small organ that stores bile and passes it from the liver to the small intestine.

Although gallbladder polyps can be cancerous (malignant), about 95 percent of gallbladder polyps are noncancerous (benign).

Types of Gallbladder Polyps

Gallbladder polyp size is often an indication of the presence of cancer

• Small gallbladder polyps — less than 1/2 inch in diameter — are typically benign and, in most cases, don’t need to be treated.
• Gallbladder polyps larger than 1/2 inch –  in diameter have a greater likelihood of being or becoming malignant.
• Gallbladder polyps larger than 3/4 – inch have a high probability of being malignant.

Symptoms of Gallbladder Polyps

Right upper abdominal pain, food intolerance, bloating, and nausea may be present. Elicitation of a positive Murphy’s sign, pain with deep palpation to the right upper abdomen, is often present.

If you have gallbladder polyps, you might not have any symptoms. However, some people do experience some symptoms. Scientists have found there’s no difference between the symptoms of people with cancerous polyps compared to those whose polyps were noncancerous, or benign.

Symptoms of gallbladder polyps include

• Nausea
• Vomiting
• Occasional pain in the upper right part of your abdomen

Diagnosis of Gallbladder Polyps

• Ultrasonography – Abdominal ultrasound is looked upon as the best available exam for diagnosing gallbladder polyps, not only because of its accessibility and low cost but also because of its good sensitivity and specificity. The polyps can be located, counted, and measured with ultrasound, and the three layers of the gallbladder wall and any abnormalities can be viewed.[rx] The polyps appear as fixed, hyperechoic material protruding into the lumen of the gallbladder, with or without an acoustic shadow. The sensitivity of abdominal ultrasound for the diagnosis of gallbladder polyps is superior to both oral cholecystography and CT and good to distinguish a cholesterol polyp from an adenoma or an adenocarcinoma. A cholesterol polyp shows as a mass with similar echogenicity to the gallbladder wall and with no shadow cone. However, the distinction is difficult to make, and the status of polyps as benign or malignant cannot be determined with abdominal ultrasound alone.[rx] Generally, polyps in the gallbladder are demonstrable in the US, only when they are over 5 mm in diameter. Sonographic differentiation between benign and malignant polyps (and calculous disease) relies greatly on the size of a single nonmobile lesion within the gall bladder. A gallstone impacted within the gallbladder wall may be easily mistaken for a polyp on ultrasound scanning.[rx]
• 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.[rx] In the diagnosis of polypoid lesions of the gallbladder, the discovery rate of B-ultrasound is significantly higher than that of CT or cholecystography. Therefore, B-ultrasonography could be first used for the diagnosis of polypoid lesions of the gallbladder. However, CT could display local anatomic correlations of the liver, gallbladder, porta hepatis, and the other organs. Enhanced CT could improve the discovery rate of polypoid lesions of the gallbladder for CT.[rx] Small polypoid lesions of the gallbladder are easily detected by the US, but accuracy based solely on the US is controversial.[rx] The accuracy of sonography for diagnosing polypoid lesions of the gallbladder was poor. Many of the small polyps seen on sonography most likely represented a stone embedded in the gallbladder wall or other abnormality.[rx]
• 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.[rx]
• 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. In view of patient comfort and no requirement for sedation, it was considered that HRUS is likely to become an important diagnostic modality for the differential diagnosis and staging of gallbladder polypoid lesions and early gallbladder cancer.[rx]
• 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 reduction in noise level. The visualization of the gallbladder is improved in the harmonic mode.[rx]
• 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 differential diagnosis of polypoid gallbladder lesions.[rx] When diffuse and branched types were considered indicative of cancer, accuracy was 85%, sensitivity 100%, and specificity 77%. In gallbladder cancer, staining throughout the tumor was continuous, consistent with diffuse hypervascularity. In benign gallbladder polyps, staining was scattered with the flow image being uniform and small. Ultrasonographic contrast enhancement patterns, therefore, show characteristic associations with pathologic findings, serve as valuable adjuncts in the diagnosis of gallbladder diseases,[rx], and differentiate gallbladder carcinoma from other polypoid gallbladder diseases lesions.[rx]
• Endoscopic ultrasonography (EUS) – EUS is better than B-ultrasonography.[rx] EUS has gained widespread use for the diagnosis of gastrointestinal malignancies, submucosal lesions of the gastrointestinal tract, and abnormalities seen on cross-sectional imaging.[rx] 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%.[rx,rx]
• 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 improves 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.[rx,rx]
• EUS scoring system – A scoring system to predict neoplastic polyps of the gallbladder has been presented.[rx] 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 the 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.[rx]
• Computed tomography – Abdominal CT is incapable of detecting low-density lesions, and its sensitivity for the diagnosis of gallbladder polyps is not satisfied, especially when gallbladder polyps were smaller than 10 mm in diameter, but it is useful for studying gallbladder carcinoma, anatomic correlations, and for investigating metastases of the ganglia.[rx,rx] Advances in multidetector-row CT have increased its accuracy rate for the differential diagnosis of gallbladder polyps, and CT generally shows polypoid gallbladder carcinoma as an enhancing, intraluminal tissue mass denser than surrounding bile and can reliably identify neoplastic lesions.[rx] In particular, helical CT may be helpful for evaluating small polypoid lesions of the gallbladder and can differentiate neoplastic and nonneoplastic small polypoid lesions of the gallbladder and reliably identify the presence of neoplastic lesions that should be resected.[rx] The size bigger than 1.5 cm, sessile shape, and perception on unenhanced images are the main factors that differentiate neoplastic from nonneoplastic gallbladder polyps 1 cm or bigger.[rx]
• 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.[rx] It has reported that various malignant tumors may show high signal intensity on diffusion-weighted MR imaging (DWI), reflecting their high cellularity and/or their long relaxation time. Therefore, a high b-value DWI may be useful for differentiating between benign and malignant polypoid gallbladder lesions.[rx]
• 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.[rx]
• Intravenous cholecystography – Intravenous cholecystography is a safe technique, but gallbladder polyps do not become sufficiently opaque.[rxrx]
• 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.[rx]
• Transabdominal ultrasonography – Transabdominal ultrasound (TAUS), encompasses conventional ultrasound (CUS), high-resolution ultrasound (HRUS), three-dimensional ultrasound, and contrast-enhanced ultrasound (CEUS). CUS and HRUS are easily accessible, cheap, non-invasive tests[rx] and are the most widely used modalities for diagnosing and following up gallbladder polyps. However, other studies have been performed to assess the effectiveness of the other forms of ultrasonography mentioned above[rx,rx].
• 3D-US is an emerging – modality that eliminates the operator dependency seen in 2-dimensional CUS. Research for this imaging modality is minimal but a study of 80 patients with gallbladder polyps found that there was agreement in the diagnosis in 89% of cases when both techniques were applied[rx]. This study however found that 3D-US did have difficulty detecting polyps less than 4mm, but it is predicted that as technology continues to evolve this issue will decline in the future[rx]. Current research, therefore, does not support the routine use of 3D-US for evaluating gallbladder polyps.
• Endoscopic ultrasound – EUS works at a higher frequency as described above and enables the transducer to be in closer proximity to the target tissue, therefore, hypothetically improving diagnostic accuracy[rx]. It is, however, an invasive examination associated with a small risk of bleeding and upper gastrointestinal perforation and presents a higher risk of complications than all forms of TAUS[rx].
• Computed tomography – CT imaging is widely used in the staging of gallbladder adenocarcinoma[rx]. However, some research has been performed to assess if it may also play a role in differentiating between true and “pseudo”- polyps and for long-term surveillance[rx]. The accuracy of CT imaging was assessed in 31 patients with polypoid lesions of the gallbladder of 3cm or less. The CT diagnosis was accurate in 87% of cases however, only 5 polyps were less than 11 mm and therefore this study provides us with limited evidence regarding the role of CT in this group of patients[rx].
• Magnetic resonance imaging – Minimal research has been performed looking at the role of MRI in differentiating between benign and malignant gallbladder polyps. A small study[rx] demonstrated in 10 benign polyps and 13 malignant polyps that the ADC values of the malignant lesions were significantly lower than that seen in the benign lesions. They concluded that diffusion-weighted MR imaging may play a role in diagnosing benign and malignant polyps[rx]. However, further research is warranted to establish if MRI can improve the accuracy of diagnosing gallbladder polyps.

Treatment of Gallbladder Polyps

Gallbladder polyps that have the appearance of pseudo or cholesterol polyps, in asymptomatic patients, can be followed with yearly gallbladder ultrasounds. These patients have a very low malignant risk. If serial ultrasounds reveal that the polyp is enlarging or if the patient becomes symptomatic, then cholecystectomy should be recommended. Patients with symptoms of chronic cholecystitis are usually best treated with laparoscopic or open cholecystectomy. Polyps that are 1 cm or greater in size should undergo cholecystectomy due to the increased risk of developing gallbladder cancer. Early intervention is preferred because an early gallbladder neoplasm has a much higher rate of cure than a more advanced lesion. In fact, stage 0 gallbladder cancer has about an 80% 5-year survival rate, and stage 1 has less than a 50% survival rate. Less than 10% of all gallbladder cancers are diagnosed at stage 1 or lower. More advanced gallbladder cancers require an open cholecystectomy with resection of the gallbladder fossa of the liver along with regional lymph node removal. [rx][rx]

Relation between gallbladder stones and gallbladder polyps

The purpose of one study was to determine the clinical characteristics of subjects with gallbladder polyps and cholelithiasis compared with those with gallbladder polyps only. No significant difference in the mean interval change of polyp size during the follow-up period between the study and control groups was noted. A significantly higher proportion of examinees in the study group had attacks of acute cholecystitis compared with the control group. By multivariate logistic regression analysis, gallbladder wall thickening on initial ultrasonography (US) and the interval increase in the size of the gallbladder polyps were significant independent risk factors for cholecystectomy. No gallbladder cancer occurred during the follow-up period. There was, therefore, no significant difference in delta polyp size between the examinees with gallbladder polyps and cholelithiasis and those with gallbladder polyps only.[rx]

Some patients who are confirmed to have polypoid lesions of the gallbladder through cholecystectomy are associated with gallstones. Symptoms were significantly associated with malignant polyp compared with the benign polyp. The association of symptom and presence of associated gallstone was separately analyzed. Significant association of symptom to associated gallstone was not found. However, symptomatic cases tended to increase with the increase in polyp size. Therefore, speculation can be made that symptoms may be associated with the size of the polyp rather than the association of gallstone.[rx]

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.

References