Usually, what is clinically referred to as gallbladder polyps actually refers to gallbladder polyp-like lesions, also known as gallbladder augmentation lesions, which are benign occupying lesions in the gallbladder cavity, mostly cholesterol polyps, mostly asymptomatic, and some patients only have mild epigastric discomfort or vague pain, and are generally considered to be a predisposing factor for gallbladder cancer. The disease should be treated mainly by surgery and supplemented by non-operative treatment.
Disease Introduction
Gallbladder polyp is the abbreviation of various benign elevations of the gallbladder mucosa, and refers broadly to lesions that protrude or bulge into the gallbladder cavity, either spherical or hemispherical, with or without a tip, and mostly benign. Because of the mild symptoms, the disease often causes delays in patients. The current management of gallbladder polyps is mainly surgical.
Classification of the disease
1. Non-neoplastic lesions: cholesterol polyps are the most common, followed by inflammatory polyps, adenomatous hyperplasia and adenomyoma.
(1) cholesterol polyps: cholesterol deposition is an important cause of gallbladder polyps, tumor polyps if a single lesion, there is a clinical differentiation. Cholesterol polyps are mild even with inflammation, and no carcinoma has been reported so far.
(2) Inflammatory polyp: a kind of granuloma caused by inflammatory stimulation, about 5mm in diameter, single or multiple. There is obvious inflammation in the gallbladder wall around the polyp, but no carcinoma has been reported so far.
(3) Adenomatous hyperplasia: a proliferative lesion that is neither inflammatory nor tumor, a soft yellow wart, about 5mm in diameter, single or multiple. There is a possibility of cancer.
(4) adenomyoma: medical also known as adenomyosis, there are diffuse, segmental type and limited three. Adenomyoma is a proliferative lesion that is neither inflammatory nor neoplastic, and may become cancerous.
2.Neoplastic lesion: benign adenoma is the main lesion, and malignant is mainly gallbladder cancer.
(1) Adenoma: Most of them are solitary, polyps with tissues, the shape can be papillary or non-papillary, the malignant rate is about 30%, the chance of cancer is positively correlated with the size of adenoma. Simple adenoma of the gallbladder can be clinically asymptomatic. It is believed that the incidence of adenoma of gallbladder is very low, and although it has the possibility of cancer, it is not a big threat to the population.
(2) Adenocarcinoma: There are papillary, nodular and infiltrative types. The first two are bulging lesions, while the infiltrative type is not a polypoid lesion of the gallbladder. Therefore, gallbladder carcinoma showing polypoid lesions is often early and has a good prognosis.
Pathogenesis and pathophysiology
Under normal conditions, these two genes are in a relative equilibrium, but when the body’s resistance decreases, the immune cells’ ability to monitor the above two genes decreases, and coupled with gallbladder inflammation and abnormal cholesterol metabolism, genetic mutations occur, causing the gallbladder wall cells to undergo an abnormal proliferation and grow into the lumen of the gallbladder. The gallbladder polyp is an abnormal proliferation of cells in the gallbladder wall, and grows into the gallbladder cavity.
Clinical symptoms of the disease
The symptoms of gallbladder polyps are usually mild or even asymptomatic, and only occasional ultrasound examinations reveal the presence of lesions in the gallbladder. A small number of patients have epigastric discomfort, nausea and vomiting, loss of appetite, abdominal pain in the right upper abdomen or right quarter rib area, with radiation to the right shoulder and back, without fever and jaundice. It may also cause jaundice, cholecystitis, biliary bleeding, pancreatitis, etc. Long-tipped polyps located in the neck of the gallbladder may present with biliary colic and acute attacks of inflammation and infection.
Prevalent groups
The age of onset of the disease is 23-55 years old, more males than females, and people with the following conditions are more likely to develop the disease:
( 1) people who do not eat breakfast or rarely eat breakfast and have an irregular diet;
( 2) Frequent consumption of alcohol, oily food, high cholesterol food, animal offal and irregular diet;
( 3) social life and work pressure, often appear irritable, depressed mood, less physical activity;
( 4) work tension often stay up late and irregular life. In addition, there is a certain correlation between obesity and men, but not women.
Diagnosis and differentiation of auxiliary examination
Ultrasound
(1) Ultrasound diagnosis is sensitive and accurate, and can be repeatedly traced, so it is the preferred diagnostic method for biliary tract disorders. The protrusion of the gallbladder wall with moderate to strong echogenicity is more common in benign cases, while hypoechogenicity is more common in malignant cases. This shows that ultrasound can improve the diagnosis rate of benign and malignant gallbladder polyp pathology.
(2) Ultrasound is a simple, easy, accurate, painless, non-invasive and economical means of examination, which can avoid surgical delays and surgical blindness.
(3) However, ultrasound examination has certain limitations and false negative rate for the diagnosis, characterization and differential diagnosis of this disease. For example, when the lesion is small and located in the neck of gallbladder, or when there are gallbladder stones, it is easy to miss the diagnosis, and it is also difficult to qualify and differentiate.
Gallbladder CT
The high resolution of CT and the clearer visualization after intravenous injection of cholangiocontrast can help to make a definite diagnosis and evaluate the surgery, but CT has some limitations and cannot detect polyp-like lesions <10 mm in diameter.
The above two methods can make a definite diagnosis of gallbladder polyps and evaluate the surgical method.
Differential diagnosis
Clinical symptoms of gallbladder polyps are non-specific and most patients are found during physical examination. The diagnosis of gallbladder polyps mainly relies on ultrasound examination.
(1) If multiple high-intensity echogenicity with floating sensation and wise-tail sign are found, it is suggested to be cholesterol polyp.
(2) Small elevations at the base of the gallbladder with small round vesicles and scattered echogenic spots suggest adenomyoma
(3) Gallbladder stones with strong echogenicity, with acoustic shadowing, and changing position with body movement.
(4) Gallbladder polyps are more difficult to distinguish from early gallbladder cancer
(1) Patients with benign lesions are mostly younger than 60 years old, therefore, the possibility of malignancy should be carefully excluded in patients with gallbladder polyp-like lesions over 60 years old
②Patients with malignant lesions often have more definite episodic pain in the right upper abdomen, while patients with benign lesions often have milder symptoms or no symptoms at all
③Patients with cholecystitis and cholelithiasis are less likely to have malignant lesions in the gallbladder
④Polyps larger than 10 mm in diameter, non-tipped polyps, and solitary polyps have a significantly higher chance of malignant lesions.
⑤ Ultrasound findings such as substantial masses filling the gallbladder, irregular thickening of the gallbladder wall, and irregular contours of polyps are often imaging features of malignant lesions.
(5) Gallbladder adenoma mainly appears on ultrasound as a moderate intensity echogenic cluster on the wall of gallbladder without acoustic shadow, does not move with body position change, and has a tip or broad base. When irregular thickening of the gallbladder wall is detected, it indicates the possibility of cancerous transformation of the gallbladder adenoma.
Treatment
The indications for surgery of gallbladder polyps are:
(1) Diameter >12mm.
(2) Solitary gallbladder polyp-like lesion.
(3) Complicated gallbladder stones.
(4) Patients aged >50 years.
(5) Multiple polyps with a short-term tendency to increase in size or thickening of the gallbladder wall. Other experts believe that the indications for surgery of gallbladder polyps are:
(1) Single polyp >50 years old, diameter >10mm or combined with gallstones should be surgically removed.
(2)Surgery can be considered for those who have obvious clinical symptoms and whose regular medical treatment is ineffective and affects their work and life.
(3) If the symptoms are relieved after medical treatment or there is no clinical symptom, B ultrasound can be used for regular observation (3-6 months), and surgery can be performed if the polyp is found to be increasing in size.
Treatment
Gallbladder polyps can be clinically inactive unless they cause cholecystitis. In addition to traditional large incision resection, laparoscopic cholecystectomy and small incision cholecystectomy, as well as biliary polypectomy, are more commonly used for surgical treatment.
(1) Laparoscopic cholecystectomy: it has the advantages of smaller trauma and faster recovery. The indications for surgery are no serious adhesions between the gallbladder and the surrounding area and no other contraindications.
The preoperative basis for Ⅰ adhesions is not heavy: the wall of gallbladder is not thick and smooth on ultrasound, the oral cholangiocontrast is visualized, and the function of concentration is available.
Laparoscopic cholecystectomy is contraindicated in patients with the following combined symptoms or diseases:
①Patients who are not suitable for general anesthesia;
②Patients with jaundice or history of severe jaundice;
(iii) patients with bile duct stones;
④Patients with bleeding tendency;
⑤ Combined with cirrhosis portal hypertension;
(6) Those with a history of upper abdominal surgery;
(7) Combined with pregnancy;
(viii) Excessively obese.
(2) Small-incision cholecystectomy: small-incision cholecystectomy can avoid many drawbacks of large-incision surgery and has obvious effects. Small incision is widely used, and it is feasible to carry out common bile duct exploration, stone extraction and drainage for those with thin abdominal wall, and it has the characteristics of less postoperative pain, faster recovery and less complications. Therefore, small incision cholecystectomy has the advantages of small trauma, fast recovery and low complications.
(3) Biliary polyp removal: If the patient has the desire to preserve the gallbladder and is under 60 years old and meets the criteria for prophylactic gallbladder removal, laparoscopic choledochoscopy combined with biliary polyp removal biopsy can be performed for these patients on a trial basis, and finally, depending on the pathological nature of the polyps during the operation, the gallbladder can be removed or retained. In this way, the gallbladder of some patients can be preserved to the greatest extent possible.
Disease Prevention
(1) Have a regular diet: Eat a good breakfast. The bile in the gallbladder has the function of digesting food. If patients do not eat regularly, especially if they do not eat breakfast, the bile secreted by the gallbladder will not be utilized, resulting in the bile remaining in the gallbladder for too long, thus stimulating the gallbladder to form gallbladder polyps or increasing the size of the original polyps.
(2) Adhere to a low cholesterol and low fat diet: Excessive cholesterol intake not only increases the burden on the patient’s liver, but also causes excess cholesterol to crystallize, accumulate and precipitate on the gallbladder wall, thus forming gallbladder polyps. Therefore, patients should reduce their cholesterol intake. In particular, high cholesterol foods should not be consumed at dinner. Such as eggs, animal offal, fish without scales, seafood and fatty meat.
(3) To ensure a healthy lifestyle: Patients should overcome the usual unhealthy lifestyle habits, prohibit smoking, alcohol and alcoholic beverages, avoid staying up late, maintain a good psychological state, often participate in some physical exercise to enhance physical fitness and strengthen the body’s ability to resist disease. If necessary, you can also take hawthorn, chrysanthemum, cassia seeds and other medicinal tea to drink regularly to achieve the purpose of lowering cholesterol.
Diet attention
Patients with gallbladder polyps should eat more beneficial food, it is appropriate to eat more food as follows.
1, it is advisable to eat more fresh fruits and vegetables, low-fat, low-cholesterol food
2, it is advisable to eat more dry beans and their products.
3, it is advisable to use vegetable oil, not animal oil.
4, eat less spicy food
5.Do not use oil frying, deep-frying, baking, smoking cooking methods.
Notes on the diet of patients with gallbladder polyps:
(1) eat less high-fat, high-cholesterol food.
(2) eat more foods rich in vitamin A, such as carrots, tomatoes, etc. Vitamin A can reduce the formation of cholesterol crystals.
(3) Increase the ratio of protein and carbohydrate in foods to ensure caloric needs and facilitate the production of liver glycogen.
(4) Reduce the fiber content, less dregs diet can also reduce the stimulation of the stomach and intestines.
(5) Increase the number of meals to stimulate bile secretion and reduce bile stagnation and concentration in the gallbladder.