Polypoid lesions of the gallbladder



OVERVIEW

Definition.

Gallbladder polypoid lesions is a collective term for all elevated lesions of the gallbladder mucosa found on imaging.

Because of the difficulty in confirming the nature of the diagnosis preoperatively, they are referred to generically as gallbladder polypoid lesions, also known as gallbladder augmentation lesions.

Classification

Classification according to pathological nature

Including adenomas and adenocarcinomas, other rare ones include hemangiomas, lipomas, smooth muscle tumors, and neurofibromas.

Such as cholesterol polyps, inflammatory polyps, adenomatous hyperplasia, etc., and rare such as adenomatous hyperplasia, yellow granuloma, ectopic gastric mucosa or pancreatic tissue.

Among them, cholesterol polyps are the most common, about 50% to 87%.

Morbidity

Polypoid lesion of gallbladder is one of the common diseases of gallbladder, the incidence rate of domestic population is about 1%~9%, accounting for 4.2%~12.3% of cholecystectomy cases.

The ultrasound detection rate of gallbladder polypoid lesions in adult physical examination in China is 4.2%-6.9%.

Etiology

Causes

The etiology of gallbladder polypoid lesions is still unclear, and is generally believed to be caused by the following factors.

Cholesterol metabolism disorder

Impaired cholesterol metabolism can lead to cholesterol precipitation in the gallbladder lumen, thus causing cholesterol polyps.

Gallbladder stones or chronic inflammation

When combined with gallbladder stones or chronic cholecystitis, due to long-term inflammatory stimulation, hyperplasia of the gallbladder mucosa can form inflammatory polyps, which are usually multiple.

Risk factors

The following factors increase the risk of developing gallbladder polypoid lesions and are considered high risk factors for the disease.

Obesity

Obese people may have abnormal cholesterol metabolism, which may lead to cholesterol polyps.

Irregular diet

Irregular diet, especially lack of attention to breakfast, may lead to the accumulation of bile in the gallbladder, which may stimulate the gallbladder wall to produce gallbladder polyps.

Gallbladder stones and cholecystitis

Gallbladder stones and cholecystitis are mutual facilitators, both of which can constantly stimulate the gallbladder wall, resulting in gallbladder polyps.

Drinking alcohol for many years

Alcohol can directly damage liver function, cause liver and gallbladder dysfunction, and disrupt the secretion and discharge of bile, which can stimulate the gallbladder to form new polyps or make the original polyps grow and become bigger.

Eating high fat, high cholesterol food

High fat, high cholesterol diet people bile cholesterol increases, easy to form cholesterol polyps.

Type II diabetes mellitus combined with hypercholesterolemia

When type II diabetes mellitus is combined with significantly higher levels of total blood cholesterol and LDL cholesterol, the probability of finding polypoid lesions in the gallbladder is also significantly higher.

Symptoms

Polypoid lesions of the gallbladder are usually asymptomatic and are usually detected by ultrasonography during physical examination.

In a few cases, there may be right upper abdominal pain, nausea and vomiting, loss of appetite, fever, and rarely obstructive jaundice.

Main symptoms

Right upper abdominal pain

If the lesion is located in the neck of the gallbladder or combined with gallbladder stones, right upper abdominal pain may occur.

It usually occurs after meals and worsens after eating greasy food.

It is often colicky, and the pain may radiate to the right shoulder.

Nausea, vomiting, loss of appetite

Abdominal pain may be accompanied by gastrointestinal symptoms such as nausea, vomiting, and loss of appetite, and aggravated by eating greasy food.

Fever

Gallbladder polyps can be combined with cholecystitis and gallbladder stones, which can cause fever when secondary bacterial infection occurs.

Other symptoms

Jaundice

When polyps block the gallbladder duct, it can lead to enlargement of the gallbladder, and yellowing of the skin and sclera can occur after the enlarged gallbladder presses on the bile duct.

When polyps are dislodged (mainly cholesterol polyps) into the common bile duct, it may lead to blockage of the common bile duct, causing yellowing of the skin and sclera.

Complications

Polypoid lesions of the gallbladder may detach and block the outlet of the pancreatic duct causing acute pancreatitis.

It can also form gallbladder stones and chronic cholecystitis due to cholesterol metabolism disorders, and can become malignant and form gallbladder cancer if it exists for a long time.

Acute pancreatitis

When polyps fall off and enter into the common bile duct, it may lead to the blockage of the common outlet of bile duct and pancreatic duct, which leads to poor drainage of pancreatic fluid, causing acute pancreatitis, and in severe cases, it may lead to acute necrotizing pancreatitis.

Symptoms such as abdominal pain, abdominal distension, nausea, vomiting, fever, etc., and even peritoneal irritation signs (abdominal pressure, rebound pain, abdominal muscle tension), lowered blood pressure, and shock may occur in severe cases.

Gallbladder stones, chronic cholecystitis

In patients with cholesterol metabolism disorder, cholesterol precipitation may not only form polyps, but also cholesterol stones.

In patients with chronic cholecystitis, the function of the gallbladder wall is affected by the presence of long-term inflammatory factors, and cholestasis may occur, resulting in the formation of gallbladder stones. In addition, if there is a biliary tract infection, it can change the composition of the bile, which is conducive to the formation of bile pigment stones.

For patients who themselves suffer from gallbladder stones, stones, severity and polyps promote each other and aggravate the condition.

Hidden pain and fullness in the upper or right upper abdomen, accompanied by dyspeptic symptoms such as belching (hiccups) and eructation, as well as biliary colic, often occur after eating greasy food.

Gallbladder Cancer

Adenomatous polyps have a higher probability of becoming cancerous, especially when combined with gallbladder stones, polyps with a diameter larger than 1 cm, without a tip or with a wider tip, single polyps, irregular thickening of gallbladder wall, irregular contour of polyps, or polyps with obvious enlargement in a short period of time, which have a higher possibility of malignant transformation.

The onset of gallbladder cancer is more insidious, mostly without specific manifestations. Clinical manifestations are mostly abdominal pain, nausea, vomiting, jaundice and weight loss.

Consultation

Department of Medicine

Department of Hepatobiliary Surgery

When symptoms such as right upper abdominal pain, nausea, vomiting, loss of appetite, fever and jaundice occur, it is recommended to consult the doctor promptly.

General Surgery

When the above symptoms occur, you may also consult the general surgery department.

Emergency Department

When symptoms such as high fever, full abdominal pain, decreased blood pressure, shock and other critical symptoms occur, it is recommended to consult the Emergency Department or call 120 emergency immediately.

Preparation for medical treatment

Preparation for medical consultation: registration, preparation of documents, common problems

Tips

Avoid taking painkillers before going to the doctor to avoid masking the symptoms, which is not conducive to a clear diagnosis.

It is recommended to fast for 6 to 8 hours before seeking medical treatment.

When right upper abdominal pain occurs, it is recommended to fast temporarily to avoid aggravation of symptoms.

Preparation Checklist

Particular attention should be paid to the time of onset of symptoms, special manifestations, etc.

Is there pain in the upper right abdomen, nausea and vomiting, fever?

Are the symptoms related to eating?

Is there yellowing of the skin and sclera?

When was the lesion of gallbladder polyps detected?

Is the diet regular? Do you eat high-fat, high-cholesterol foods? Have you been drinking alcohol for many years?

Are you always overweight? Are there any abnormalities in blood sugar or blood lipids?

Any history of gallbladder stones, cholecystitis, diabetes?

Test results in the past six months, which can be carried to the doctor

Laboratory tests: blood test, liver function, blood lipid, blood sugar.

Imaging tests: abdominal ultrasound, endoscopic ultrasound, enhanced CT, magnetic resonance imaging (MRI), and ultrasonography.

Pathologic examination: ultrasound-guided percutaneous fine needle aspiration biopsy.

Medication use in the last 3 months, if available in boxes or packages, bring them to the doctor’s office

Painkillers: e.g. ibuprofen, celecoxib

Lithotripsy or choleretic drugs: e.g. ursodeoxycholic acid, anti-inflammatory choleretic tablets

Digestive stimulants: e.g. digestive enzymes

Antibiotics: e.g. cefuroxime

Diagnosis

Diagnosis is based on

Medical history

Most patients are found during a physical examination with an abdominal ultrasound.

The patient has a history of irregular diet for many years, especially a history of skipping breakfast.

There is a history of a high-fat, high-cholesterol diet for many years.

There is a history of drinking alcohol for many years.

BMI is overweight and obese for years; there is a history of hyperlipidemia or diabetes mellitus.

A history of gallbladder stones, cholecystitis, and diabetes mellitus for many years is found.

Clinical manifestations

The disease is usually asymptomatic and is mostly detected by ultrasonography during physical examination. A few patients may have right upper abdominal pain, nausea and vomiting, loss of appetite; very rare cases may cause obstructive jaundice.

Auxiliary examination

Generally, the diagnosis can be confirmed by choosing abdominal ultrasonography, and the following tests can clarify the cause of the disease and assist in treatment.

Including blood routine, liver function, blood lipid, blood sugar.

Routine blood test to know whether there is infection.

Liver function test to know whether there is inflammation or bile duct blockage caused by changes in liver function.

Lipid and blood glucose check for the presence of abnormalities in blood lipids and blood glucose.

This includes abdominal ultrasound, endoscopic ultrasound, enhanced CT, magnetic resonance imaging (MRI), and ultrasonography.

Abdominal ultrasound can observe the morphology, location, echo characteristics, and relationship with the gallbladder wall of the polypoid lesion. It can initially help to diagnose whether the polypoid lesion is a true tumor or a pseudotumor, whether it meets the indications for surgery, and whether further examination is needed.

Endoscopic ultrasound plays an important role in identifying cholesterol polyps, adenomas and gallbladder cancer.

Enhanced CT or Magnetic Resonance Imaging (MRI) examination is mostly used to make identification of whether cancer is present, etc.; it can help to determine the relationship between the polypoid lesion and the gallbladder wall and the surrounding tissues, and can help to determine the nature of the polypoid lesion of the gallbladder.

Ultrasonography: it can check the blood flow of polyps, help to identify tumorigenic and non-tumorigenic polyps, and provide help for whether to treat them surgically.

This includes ultrasound-guided percutaneous fine needle aspiration biopsy.

When in vitro non-invasive examination cannot determine whether gallbladder polypoid lesions appear malignant, puncture biopsy can be chosen to assist in the diagnosis.

However, it should be chosen with caution because of the possibility of secondary hemorrhage and the possibility of spreading through the needle hole in case of cancer.

Differential diagnosis

The history and clinical manifestations of gallbladder polypoid lesion are atypical, and it is easy to be confused with gallbladder cancer and gallbladder stones, which need to be differentiated.　

Gallbladder cancer

Similarities: both may present with abdominal pain, nausea and vomiting.

Differences

Gallbladder stones

Similarity: both may present with abdominal pain in the right upper abdomen.

Differences

Treatment

Aim of treatment: to cure the disease, relieve symptoms such as right upper abdominal pain, nausea and vomiting, and prevent cancerous transformation.

Treatment principle

Non-surgical treatment

General treatment

Diet: light diet, small meals, more fruits and vegetables.

Appropriate exercise: participate in exercise moderately and according to one’s ability.

Medication

Short-term application of non-steroidal anti-inflammatory analgesic drugs can be used to relieve pain symptoms when right upper abdominal pain occurs.

Commonly used drugs: ibuprofen, diclofenac sodium, celecoxib and so on.

Precautions

It can promote the secretion of bile acid and reduce the cholesterol in bile.

Commonly used drugs: ursodeoxycholic acid, suitable for some cholesterol polyps and prevent gallbladder stones.

Precautions

It is mainly applied to patients with cholesterol polyps who have dyslipidemia to lower their blood cholesterol so that gallbladder polyps do not continue to grow.

Commonly used drugs: Atorvastatin, Rosuvastatin.

Precautions

Used to control bacterial infection and relieve symptoms of biliary system infection.

Commonly used drugs: Cefuroxime, Cefoperazone, Moxifloxacin.

Precautions: Before using the drug need to clarify the patient’s history of drug use, allergy history, if necessary, do drug allergy test. Drug allergy is prohibited.

Surgery

Cholecystectomy is the treatment of choice for polypoid lesions of the gallbladder.

It mainly relies on whether there are symptoms and malignant changes to determine whether immediate surgery is needed.

Indications

Diameter > 1cm.

Those with blood flow signals detected on imaging.

Those with a diameter of <1cm, symptoms or risk factors for gallbladder cancer (age >50 years, polyps enlarged by more than 2mm, gallbladder wall thickened by more than 3mm).

Surgical procedure

Laparoscopic cholecystectomy or open cholecystectomy.

Precautions

After cholecystectomy, specimens should be taken and sent to pathology, and the subsequent treatment plan should be decided according to the results of the pathology examination.

Keep the incision clean and clear after surgery and change the medicine regularly.

After surgery, you should eat a light diet, eat small meals, avoid overeating, and avoid drinking alcohol.

Prognosis

Cure

Untreated polyps generally do not heal on their own.

For non-surgical treatment, the polyp can be stable for a long time, the prognosis is still good, but there is a possibility of malignant transformation.

If the polyp is not malignant, surgical treatment can cure the disease and the prognosis is good.

Cancer occurs, if found in time, when the lesion is in the mucous membrane layer, the prognosis is good after surgery.

Some polyps become cancerous and metastasis has already appeared when they are found, so the prognosis is poor.

Hazards

Patients with gallbladder polypoid lesions combined with other diseases (especially hyperlipidemia and obese patients) may induce acute pancreatitis, which may lead to necrotizing pancreatitis and endanger life.

Some gallbladder polypoid lesions combined with chronic cholecystitis and gallbladder stones may cause right upper abdominal pain and nausea, which can be relieved after surgical treatment.

When gallbladder polypoid lesions invade the surrounding tissues or metastasize after malignant transformation, even after surgery, the 5-year survival rate is still unsatisfactory, which can seriously affect the patient’s health and survival.

Daily

Daily Management

Dietary management

Balanced diet, less spicy, stimulating and greasy food.

Regular diet, do not overeat.

Supplement foods rich in calcium and protein, such as milk, soybean products and eggs.

Eat more fresh fruits and vegetables.

Abstain from alcohol.

Daily Management

Maintain a healthy lifestyle.

Quit smoking and drinking and ensure rest.

Exercise appropriately and choose the right type of exercise for you.

Disease monitoring

Watch for symptoms such as right upper abdominal pain, nausea, vomiting, loss of appetite, fever and jaundice.

Pay attention to whether there are changes in the maximum diameter of polyps, enlargement of polyps, thickening of gallbladder wall, etc. in the imaging examination.

If surgical treatment is adopted, the healing of incision should be observed, and whether there are symptoms of infection such as local redness, swelling, fever, worsening pain and pus flow.

Follow-up examination

Importance of follow-up: to assess the progress of gallbladder polyps.

Follow-up time: It should be set by the specialist according to the patient’s specific condition.

Tests for follow-up: abdominal ultrasound, liver function, blood tests.

Prevention

Actively treat underlying diseases such as gallbladder stones and cholecystitis.

Regular diet, especially pay attention to breakfast, small meals, avoid overeating.

Eat a light diet and avoid drinking alcohol.

Obese people, especially those with diabetes mellitus and dyslipidemia, should actively control their weight and diet to keep their weight, blood glucose and blood lipids in the normal range, and take hypoglycemic and hypolipidemic drugs if necessary.

Regular physical examination, abdominal ultrasound and other imaging tests.