Polypoid lesions of the gallbladder: diagnosis and indications for surgery

Advances in the Early Detection of Hepatobiliary Cancers

Hepatocellular cancer (HCC) and biliary tract cancers (BTCs) have poor survival rates and a low likelihood of a cure, especially in advanced-stage disease. Early diagnosis is crucial and can significantly improve survival rates through curative treatment approaches. Current guidelines recommend abdominal ultrasonography (USG) and alpha-fetoprotein (AFP) monitoring for HCC screening in high-risk groups, and abdominal USG, magnetic resonance imaging (MRI), and magnetic resonance cholangiopancreatography (MRCP) monitoring for biliary tract cancer. However, despite this screening strategy, many high-risk individuals still develop advanced-stage HCC and BTC. Blood-based biomarkers are being developed for use in HCC or BTC high-risk groups. Studies on AFP, AFP-L3, des-gamma-carboxy prothrombin, glypican-3 (GPC3), osteopontin (OPN), midkine (MK), neopterin, squamous cell carcinoma antigen (SCCA), Mac-2-binding protein (M2BP), cyclic guanosine monophosphate (cGMP), and interleukin-6 biomarkers for HCC screening have shown promising results when evaluated individually or in combination. In the case of BTCs, the potential applications of circulating tumor DNA, circulating microRNA, and circulating tumor cells in diagnosis are also promising. These biomarkers have shown potential in detecting BTCs in early stages, which can significantly improve patient outcomes. Additionally, these biomarkers hold promise for monitoring disease progression and evaluating response to therapy in BTC patients. However, further research is necessary to fully understand the clinical utility of these biomarkers in the diagnosis and management of HCC and BTCs.

A Patient with Synchronous Gallbladder and Bone Plasmacytoma

Multiple myeloma (MM) is the most common primary bone-originating tumor, whereas extramedullary plasmacytoma (EMP) is a plasma cell tumor that arises outside the bone and is most commonly found in the head and neck area. Gastrointestinal and particularly gallbladder involvement is exceedingly rare, and symptoms, if any are present, are usually similar to those seen with cholelithiasis. Treatment options usually include surgical resection and/or chemotherapy. In this report, we present a rare case of a clinically unexpected plasmablastic extramedullary plasmacytoma that was found on abdominal ultrasound (US) and magnetic resonance imaging (MRI) in a 61-year-old asymptomatic patient and led him to undergo cholecystectomy. A fluorodeoxyglucose positron emission computed tomography (FDG PET-CT) that was performed due to the onset of left thigh pain also demonstrated concurrent bone plasmacytoma. The patient is currently receiving chemotherapy and is also being prepared for autologous stem cell transplantation. In this context, we further present the diagnostic, therapeutic and prognostic challenges of EMPs. Lastly, we point out the distinct features of the plasmablastic subtype and analyze its differences compared to other histologic subtypes in achieving a successful diagnosis and management.

A New Risk Scoring System to Predict Malignancy in Gallbladder Polyps: a Single-Center Study

OBJECTIVE

Ultrasonography (US) is the most commonly used radiological method in the diagnosis of gallbladder polyps (GBPs). Patients diagnosed with GBPs on US are operated on with risk factors that do not have a high level of evidence. Our aim in this study is to determine the sensitivity of US in diagnosis GBPs, to define risk factors for neoplastic (NP) polyps, and to develop the risk scoring system.

MATERIALS AND METHODS

Between July 2011 and July 2021, 173 patients who were found to have GBPs in the pathology specimens after cholecystectomy were included in the study. Patients were divided into two groups: nonneoplastic and NP groups.

RESULTS

GBPs in patients who underwent abdominal US for any reason was 4.5%. The sensitivity of US in the diagnosis of GBPs was 56.6%. Comparison between groups, age ≥50, presence of symptoms, polyp size >12.5mm, single polyp, concomitant gallstones, and gallbladder wall thickness ≥4mm were statistically in the NP group. A risk scoring system was developed using these values. If the risk score was <4, 0.6% of GBPs was NP polyps. If the risk score was ≥4, 63.2% of GBPs were NP polyps.

CONCLUSION

Our risk scoring system can prevent unnecessary choelcystectomy. Because the incidence of NP polyps in low-risk patients (risk score <4) is extremely rare.

Risk of developing gallbladder cancer in patients with gallbladder polyps detected on transabdominal ultrasound: a systematic review and meta-analysis

OBJECTIVE

To estimate the risk of malignancy in gallbladder polyps of incremental sizes detected during transabdominal ultrasound (TAUS).

METHODS

We searched databases including MEDLINE, Embase, and Cochrane Library for eligible studies recording the polyp size from which gallbladder malignancy developed, confirmed following cholecystectomy, or by subsequent follow-up. Primary outcome was the risk of gallbladder cancer in patients with polyps. Secondary outcome was the effect of polyp size as a prognostic factor for cancer. Risk of bias was assessed using the Quality in Prognostic Factor Studies (QUIPS) tool. Bayesian meta-analysis estimated the median cancer risk according to polyp size. This study is registered with PROSPERO (CRD42020223629).

RESULTS

82 studies published since 1990 reported primary data for 67,837 patients. 67,774 gallbladder polyps and 889 cancers were reported. The cumulative median cancer risk of a polyp measuring 10 mm or less was 0.60% (99% credible range 0.30-1.16%). Substantial heterogeneity existed between studies (I2 = 99.95%, 95% credible interval 99.86-99.98%). Risk of bias was generally high and overall confidence in evidence was low. 13 studies (15.6%) were graded with very low certainty, 56 studies (68.3%) with low certainty, and 13 studies (15.6%) with moderate certainty. In studies considered moderate quality, TAUS monitoring detected 4.6 cancers per 10,000 patients with polyps less than 10 mm.

CONCLUSION

Malignant risk in gallbladder polyps is low, particularly in polyps less than 10 mm, however the data are heterogenous and generally low quality. International guidelines, which have not previously modelled size data, should be informed by these findings.

ADVANCES IN KNOWLEDGE

This large systematic review and meta-analysis has shown that the mean cumulative risk of small gallbladder polyps is low, but heterogeneity and missing data in larger polyp sizes (>10 mm) means the risk is uncertain and may be higher than estimated.Studies considered to have better methodological quality suggest that previous estimates of risk are likely to be inflated.

Management of Incidentally Detected Gallbladder Polyps: Society of Radiologists in Ultrasound Consensus Conference Recommendations

Gallbladder polyps (also known as polypoid lesions of the gallbladder) are a common incidental finding. The vast majority of gallbladder polyps smaller than 10 mm are not true neoplastic polyps but are benign cholesterol polyps with no inherent risk of malignancy. In addition, recent studies have shown that the overall risk of gallbladder cancer is not increased in patients with small gallbladder polyps, calling into question the rationale for frequent and prolonged follow-up of these common lesions. In 2021, a Society of Radiologists in Ultrasound, or SRU, consensus conference was convened to provide recommendations for the management of incidentally detected gallbladder polyps at US. See also the editorial by Sidhu and Rafailidis in this issue.

Development and Validation of a Preoperative Nomogram for Predicting Benign and Malignant Gallbladder Polypoid Lesions

Purpose

The purpose of this study was to develop and validate a preoperative nomogram of differentiating benign and malignant gallbladder polypoid lesions (GPs) combining clinical and radiomics features.

Methods

The clinical and imaging data of 195 GPs patients which were confirmed by pathology from April 2014 to May 2021 were reviewed. All patients were randomly divided into the training and testing cohorts. Radiomics features based on 3 sequences of contrast-enhanced computed tomography were extracted by the Pyradiomics package in python, and the nomogram further combined with clinical parameters was established by multiple logistic regression. The performance of the nomogram was evaluated by discrimination and calibration.

Results

Among 195 GPs patients, 132 patients were pathologically benign, and 63 patients were malignant. To differentiate benign and malignant GPs, the combined model achieved an area under the curve (AUC) of 0.950 as compared to the radiomics model and clinical model with AUC of 0.929 and 0.925 in the training cohort, respectively. Further validation showed that the combined model contributes to better sensitivity and specificity in the training and testing cohorts by the same cutoff value, although the clinical model had an AUC of 0.943, which was higher than 0.942 of the combined model in the testing cohort.

Conclusion

This study develops a nomogram based on the clinical and radiomics features for the highly effective differentiation and prediction of benign and malignant GPs before surgery.

Triphasic dynamic enhanced computed tomography for differentiating cholesterol and adenomatous gallbladder polyps

BACKGROUND

Triphasic dynamic enhanced computed tomography (CT) scans were acquired to identify cholesterol and adenomatous gallbladder (GB) polyps that were inaccurately diagnosed before surgery.

PURPOSE

To evaluate the CT findings of 1.0- to 2.0-cm GB polyps for differentiating between cholesterol and adenomatous polyps.

METHODS

Fifty-two patients with GB polyps were treated surgically from December 2017 to July 2020 and were retrospectively divided into 2 groups according to the postoperative pathologic results: a cholesterol group with 30 patients and an adenomatous group with 22 patients. Unenhanced and triphasic dynamic enhanced CT scans were performed for all the patients within 2 weeks before surgery. The CT image parameters were measured and analyzed by 2 senior radiologists blinded to the pathological diagnoses.

RESULTS

Of the 22 patients in the adenomatous group, 77.3% were female and 22.7% were male, with a mean age of 53.5 years; among the 30 patients in the cholesterol group, 66.7% were female and 33.3% were male, with a median age of 50.1 years. The CT image parameters of all 52 patients with GB polyps were analyzed. Significant differences were found in the arterial phase CT values, portal venous phase CT values, delayed phase CT values, ∆CT1 values (portal venous phase CT minus delayed phase CT values), and ∆CT2 values (arterial phase CT minus delayed phase CT values) between the cholesterol and adenomatous polyp groups (p < 0.05). In differentiating the two groups, the ∆CT1 and ∆CT2 values were superior to the arterial, portal venous and delayed phase CT values regarding both sensitivity and specificity.

CONCLUSION

The arterial phase CT values, portal venous phase CT values, delayed phase CT values, and ∆CT values (including ∆CT1 and ∆CT2) from triphasic dynamic enhanced CT scans can differentiate the nature of gallbladder polypoid lesions, with the ∆CT values having the highest sensitivity and specificity.

The Role of Endoscopic Ultrasound in the Diagnosis of Gallbladder Lesions

Gallbladder (GB) diseases represent various lesions including gallstones, cholesterol polyps, adenomyomatosis, and GB carcinoma. This review aims to summarize the role of endoscopic ultrasound (EUS) in the diagnosis of GB lesions. EUS provides high-resolution images that can improve the diagnosis of GB polypoid lesions, GB wall thickness, and GB carcinoma staging. Contrast-enhancing agents may be useful for the differential diagnosis of GB lesions, but the evidence of their effectiveness is still limited. Thus, further studies are required in this area to establish its usefulness. EUS combined with fine-needle aspiration has played an increasing role in providing a histological diagnosis of GB tumors in addition to GB wall thickness.

Dual-energy CT to differentiate gallbladder polyps: cholesterol versus adenomatous

BACKGROUND

Dual-energy computed tomography (DE-CT) scans were acquired to identify cholesterol and adenomatous gallbladder (GB) polyps, which have not been well evaluated before surgery.

PURPOSE

To evaluate the DE-CT findings of GB polyps 1.0-2.0 cm in size and differentiate between cholesterol and adenomatous polyps.

MATERIAL AND METHODS

Forty-six patients with GB polyps were surgically treated from December 2017 to December 2019 and divided into two groups according to their postoperative pathologic results: a cholesterol group with 26 patients and an adenomatous group with 20 patients. All of these patients underwent DE-CT imaging with tube voltages of 80 kVp and 140 kVp within two weeks before surgery. Mean attenuation values were measured for every GB polyp at 80/140 kVp and at 40/140 keV. The mean attenuation value changes between 140 kVp and 80 kVp (MAVC_{140-80 kVp}) and mean attenuation value changes between 100 keV and 40 keV (MAVC_{100-40 keV}) were calculated.

RESULTS

The CT image parameters of all 46 patients with GB polyps were analyzed. There were significant differences in MAVC_{140-80 kVp} and MAVC_{100-40 keV} between cholesterol and adenomatous polyps (P <0.05); these values were positive for cholesterol polyps and negative for adenomatous polyps.

CONCLUSION

The unique energy spectrum information provided by DE-CT scans is helpful in differentiating between cholesterol and adenomatous polyps 1.0-2.0 cm in size.

Gallbladder Disorders: A Comprehensive Review

Gallbladder disorders encompass a wide breadth of diseases that vary in severity. We present a comprehensive review of literature for the clinical presentation, pathophysiology, diagnostic evaluation, and management of cholelithiasis-related disease, acute acalculous cholecystitis, functional gallbladder disorder, gallbladder polyps, gallbladder hydrops, porcelain gallbladder, and gallbladder cancer.

Gallbladder polyps: evolving approach to the diagnosis and management

Gallbladder (GB) polyp is a mucosal projection into the GB lumen. With increasing health awareness, GB polyps are frequently found using ultrasonography during health screening. The prevalence of GB polyps ranges between 1.3% and 9.5%. Most patients are asymptomatic and have benign characteristics. Of the nonneoplastic polyps, cholesterol polyps are most common, accounting for 60%-70% of lesions. However, a few polyps have malignant potential. Currently, the guidelines recommend laparoscopic cholecystectomy for polyps larger than 1 cm in diameter due to their malignan potential. The treatment algorithm can be influenced by the size, shape, and numbers of polyps, old age (>50 years), the presence of primary sclerosing cholangitis, and gallstones. This review summarizes the commonly recognized concepts on GB polyps from diagnosis to an algorithm of treatment.

Clinical relevance of gallbladder polyps; is cholecystectomy always necessary?

BACKGROUND

Gallbladder polyps are common incidental findings during abdominal ultrasonography. Cholecystectomy is recommended for polyps equal or greater than 10 mm on ultrasound due to their malignant potential. However, the majority of lesions appear to be pseudopolyps with no malignant potential. Our aim was to determine the correlation between ultrasonographic findings and histopathological findings after cholecystectomy for gallbladder polyps in two institutions.

METHOD

A retrospective analysis was performed at two Dutch institutions of patients who underwent cholecystectomy. All cholecystectomies for suspected gallbladder polyps between January 2010 and August 2017 were included. Ultrasonographic and histopathological reports were analyzed.

RESULTS

A total of 108 patients underwent cholecystectomy for gallbladder polyps. At abdominal ultrasound sixty-five patients (60.2%) were diagnosed with multiple gallbladder polyps. The mean diameter of the polyps was 11 mm. On pathological examination after cholecystectomy, only three specimens harbored true polyps. No anomalies were found in 48 (44%) patients and 51 (47%) had cholesterolosis.

CONCLUSION

The prevalence of true gallbladder polyps was much lower in this study than reported in literature. After cholecystectomy for gallbladder polyps diagnosed by ultrasound, 97% of patients had non-neoplastic or not identifiable lesions in the gallbladder. These findings question the usefulness of current guidelines for management of suspected gallbladder polyps.

The accuracy of ultrasonography for diagnosis of gallbladder polyps

INTRODUCTION

Gallbladder polyps (GBPs) are gallbladder lesions which can progress to gallbladder malignancy. The incidence has been estimated as high as 12.1% of all cholecystectomy patients. Gallbladder malignancy typically presents late, and therefore carries a poor prognosis. By identifying potential GBPs early, it would be possible to treat polyps before they undergo malignant change. The current gold standard for GBP identification is with histological examination which is performed after cholecystectomy. This study sought to assess whether radiological imaging could reliably identify GBPs and therefore guide management.

METHODS

1000 consecutive patients already undergoing cholecystectomy were sampled from two UK hospitals. Patients who underwent ultrasonography and had histological analysis of their gallbladders were selected. Overall 905 patients were included in the study.

RESULTS

There were 12 histologically confirmed GBPs in the cohort (1.33%). US correctly detected 1 GBP, with a sensitivity of 8.3% (95% CI 0.2-38.5%) and specificity of 96.0% (95% CI 94.5-97.2%). The overall accuracy was 94.8 (95% CI 93.2-96.2%).

CONCLUSION

These data show that US is an ineffective tool for GBP identification. The lack of prior operator exposure, imprecise nature of US and possible obstruction of images from underlying gallstone disease delivered a high rate of false positives.

IMPLICATIONS FOR PRACTICE

Surgical or oncological decisions regarding GBPs should not be based upon US findings alone as this would lead to unnecessary interventions. MRI should be investigated as an alternative imaging modality for GBP identification, as its differentiation of soft tissues could guide surgical management.

Endoscopic mucosal resection of a bile duct polyp: A case report

BACKGROUND

Bile duct polyps are difficult to diagnose and are usually excised by open abdominal surgery or snare polypectomy using choledochoscopy via the T-tube sinus tract. However, these two resection methods require the surgeon to open the abdomen and cut the bile duct to place the “T” tube. Moreover, simple snare polypectomy, without submucosal injection, can only remove pedunculated polyps and not flat polyps. Therefore, a new method is required for the excision of bile duct polyps, including flat polyps.

CASE SUMMARY

A 63-year-old woman was hospitalized following epigastric pain lasting a month. She had a 30-year history of cholelithiasis and had undergone cholecystectomy because of cholecystolithiasis, and had undergone cholangiolithotomy twice due to choledocholithiasis. Computed tomography (CT) and magnetic resonance imaging showed a communication between the bile duct and duodenal bulb. Inside the communication, CT showed a high-density shadow which was a hypointense lesion in T2 weighted image. The lesion showed no enhancement in T1 weighted image contrast enhanced. Gastroscopy revealed an incarcerated bile duct stone in the anterior wall of the duodenal bulb, which was removed with a basket under gastroscopy. Thereafter, a choledochoduodenal fistula was revealed. Finally, a flat polyp was detected in the lower part of the common bile duct and was removed by endoscopic mucosal resection (EMR) through the fistula. To our knowledge, this is the first reported case of the removal of a bile duct polyp using EMR.

CONCLUSION

EMR is a safe, effective, and low-cost method for the resection of all bile duct polyps.

Giant intracholecystic papillary tubular adenoma of the gall bladder with gall stones in an elderly woman; case report

Gall bladder polyps occur in 0.4% of patients undergoing cholecystectomy, the majority of gall bladder polyps are benign, they are classified into 3 types: epithelial or adenomatous polyps, mesenchymal polyps, and pseudopolyps. Gall bladder polys mostly affect females and those more than 50 years of age. Ultrasound is a very sensitive tool in the diagnosis.

An 88-year-old woman presented with epigastric pain and right hypochondrial pain, fever, and vomiting for 1 week. Clinical examination showed jaundice and tenderness at the right hypochondrial region. Investigations showed elevated WBC, bilirubin level and the alkaline phosphatase. MRCP showed multiple gall stones with a large irregular polyp in the fundus of the gall bladder, and dilated common bile duct with multiple stones in the lumen of common bile duct. Cholecystectomy was done with exploration of the common bile duct with extraction of stones, T-tube was placed inside the CBD. At the 14th day T-tube cholangiography was done which showed passage of the dye to the duodenum, the tube was extracted and the patient was discharged home with no postoperative complications. The histopathology showed intracholecystic papillary tubular adenoma of the gall bladder with no evidence of malignancy.

The general indications of surgery for gall bladder polyps include the size if more than 10 mm especially if solitary, the presence of associated gall stones, the age if more than 60 years, and if the polyps are causing symptoms. In this patients the large size of the polyp and obstructive jaundice were the two indications for surgery.

•

Gall bladder polyps are commonly diagnosed and may be associated with gall stones.

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Most patients are worried about the possibility of malignancy.

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Laparoscopic cholecystectomy can be safely done when there is indication for surgery.

Gallbladder Polyps: Rare Lesions in Childhood

OBJECTIVE

Unlike adults, gallbladder polyps (GPs) are rare in childhood. The aim of this study was to evaluate patients with a GP diagnosis.

METHODS

Patients who were diagnosed with GP via ultrasonography from October 2012 to October 2017 were retrospectively evaluated in terms of sociodemographic characteristics and laboratory findings.

RESULTS

The study included 19 patients diagnosed with GP and followed up in our department. The patients comprised 14 (73.6%) girls with a mean age of 13.9 ± 4.1 years and a mean follow-up period of 10.2 ± 5.4 months (range, 3-26 months). The most common presenting symptom of the patients (n = 15, 78.9%) for ultrasonography was abdominal pain without biliary symptoms. Location of the polyps was in the corpus in 55% of patients, and either in the fundus (20%) or the neck of the gallbladder (25%). The average diameter of the polyps was 4.5 ± 1.6 mm (range, 2-9 mm). Multiple polyps were observed in 3 patients. No significant change in the number or size of polyps was noted at the end of the follow-up periods. Cholecystectomy was applied to 1 patient who had >5 polyps with a rapid increase in size, and the pathology report was hamartomatous polyp. There was no remarkable change in the clinical or laboratory findings of other patients during the follow-up period.

CONCLUSION

In this study, GPs could be seen in young children as young as 16 months of age and ultrasonography is sufficient for follow-up in stable and asymptomatic patients.

Neoplastic polyps in gallbladder: a retrospective study to determine risk factors and treatment strategy for gallbladder polyps

Background

Preoperative differentiation of malignant and premalignant gallbladder polyps (GBPs) from benign lesions is a key imperative to guide treatment decision-making. We aimed to characterize the various types of GBPs and sought to identify the risk factors for neoplastic polyps. Our findings may help optimize treatment strategy.

Methods

Retrospective analysis of 686 patients with post-cholecystectomy pathologically-proven GBPs between January 2003 and December 2016. The patients were classified into non-neoplastic polyp group, benign neoplastic polyp group, and adenoma canceration group. Clinical features, ultrasound findings, and results of laboratory investigations and histopathological examination were reviewed and compared between the groups.

Results

Out of 686 patients, 542 (79.0%) had non-neoplastic polyps, 134 (19.5%) had neoplastic polyps, and 10 (1.5%) had adenoma canceration. The mean age was 46.06±12.12 years; 383 (55.8%) patients were female. The median (25^th percentile, 75^th percentile) time between diagnosis and surgery in the cholesterol polyp group [24 (3.5, 60) months] was significantly longer than that in adenoma [12 (2, 60) months] and adenoma canceration [5 (0.475, 12) months] groups. The mean diameter was 1.14±0.61 cm (range, 0.5-8.4 cm). Three hundred twelve (45.5%) patients had solitary polyps and intralesional blood flow was observed in 41 (6.0%) patients. On univariate analysis, age >49.5 years, polyp size >1.15 cm, solitary polyp, intralesional blood flow, absence of symptoms, and lack of cholecystitis showed a significant association with adenoma. On multivariate analysis, polyp size (>1.15 cm), intralesional blood flow, and lack of cholecystitis were independent predictors of adenoma.

Conclusions

Polyp size >1.15 cm, intralesional blood flow, and lack of cholecystitis were predictors of neoplastic polyps. Malignant transformation of adenoma may occur over a relatively short time.

Five year experience of gallbladder polyp surveillance and cost effective analysis against new European consensus guidelines

BACKGROUND

Gallbladder polyp (GBP) surveillance seeks to identify early neoplasms, but practice varies amongst surgical units. Recent European consensus guidelines have recommended an evidence-based GBP surveillance strategy. In a tertiary centre Hepato-Pancreato-Biliary unit we examine GBP surveillance, malignant yield, and assess cost-effectiveness of the new European consensus guidelines.

METHODS

Respective data were collected from all patients with ultrasonography-detected GBPs between January 2008 and January 2013.

RESULTS

558 patients had GBPs detected on ultrasonography. Following initial ultrasonography, 304 (54.5%) had further ultrasonography surveillance of which 168 were in a formal GBP surveillance programme. Pre-malignant/malignant pathology yield was 1.97% with an annual detection rate of 12.0 cases per 1000 GBPs surveyed. Cost-effectiveness analysis of European consensus guidelines calculated annual savings of £209 163 per 1000 GBPs surveyed. Compliance with these guidelines would result in an additional 12.5% of patients under surveillance requiring cholecystectomy.

CONCLUSION

GBP surveillance uptake was suboptimal at 32.8%. The incidence of pre-malignant/malignant lesions in GBPs emphasises the importance of surveillance for early detection and management with a view to avoiding the poor outcomes associated with more advanced gallbladder cancer. Adherence to the new European consensus guidelines would be clinically cost-effective with significant potential savings demonstrated in this study.

Quantitative contrast-enhanced US helps differentiating neoplastic vs non-neoplastic gallbladder polyps

OBJECTIVES

To differentiate between large (≥ 1 cm in diameter) gallbladder (GB) non-neoplastic and neoplastic polyps using quantitative analysis of contrast-enhanced ultrasound (CEUS) findings.

METHODS

From September 2017 to May 2018, 29 patients (10 males; median age, 63 years) with GB polyps of ≥ 1 cm in diameter who were undergoing cholecystectomy were consecutively enrolled. All patients underwent preoperative conventional US and CEUS examinations. Quantitative analysis of CEUS findings using time-intensity curves between the two groups was independently performed by two radiologists. The interobserver agreement for the quantitative analysis of the CEUS results was measured using the intraclass correlation coefficient. Receiver operating characteristic analysis was performed to evaluate the diagnostic performance of CEUS examination.

RESULTS

After the cholecystectomy, the patients were classified into the non-neoplastic polyp group (n = 12) and the neoplastic polyp group (n = 17) according to the pathological results. The interobserver agreement for quantitative assessment between the two radiologists was near perfect to substantial. Quantitative assessment of the CEUS findings revealed that the rise time, mean transit time, time to peak, and fall time of non-neoplastic GB polyps were significantly shorter than those of neoplastic polyps (p < 0.001, p = 0.008, p = 0.013, and p = 0.002, respectively). The sensitivity and specificity of the quantitative CEUS parameters for the differentiation between the two groups were 76.5-100% and 75%, respectively, with an area under the curve of 0.765-0.887.

CONCLUSIONS

Quantitative analysis of CEUS findings could be valuable in differentiating GB neoplastic polyps from non-neoplastic polyps.

KEY POINTS

• Quantitative analysis of CEUS findings could be valuable in differentiating gallbladder neoplastic polyps from non-neoplastic polyps. • Quantitative analysis of CEUS findings in gallbladder polyps provides cut-off values for differentiation between neoplastic polyps and non-neoplastic polyps with near-perfect to substantial interobserver agreement.

Gallbladder polypoid lesions are inaccurately reported and undermanaged: a retrospective study of the management of gallbladder polypoid lesions detected at ultrasound in symptomatic patients during a 36-month period

AIM

To investigate whether gallbladder polypoid lesions (GPL) are accurately reported and managed by radiologists, sonographers, general practitioners (GPs) and surgeons.

MATERIALS AND METHODS

Consecutive abdominal ultrasound examinations indicating GPL in symptomatic patients performed during 2011-2013 were captured and analysed. The study comprised 244 patients who satisfied the inclusion criteria.

RESULTS

Of the ultrasound reports retrieved, 238/244 reports (98%) erroneously described the polypoid lesions as polyps. One hundred and thirty-two of the 244 (54%) reports recommended follow-up, 5/244 (2%) recommended no follow-up, 35/244 (14%) deemed the findings insignificant, and 72/244 (30%) did not comment. Regarding GP referral, 57/184 (31%) patients were correctly referred to general surgeons, 20/184 (11%) to gastroenterologists, and 107/184 (58%) were not referred to secondary care. Forty-three of the 244 patients (18%) underwent cholecystectomy. Regarding subsequent biliary presentations, 63/244 patients (26%) presented at a later date with biliary symptoms; 13/63 (21%) of these eventually had cholecystectomies with 2/13 (15%) experiencing potentially life-threatening pancreatitis episodes. Regarding the surgical approach, differences were observed in the way individual surgeons managed polypoid lesions, with some veering towards cholecystectomy, others towards follow-up ultrasound, and some towards discharge.

CONCLUSION

GPL tend to be misreported by radiologists and sonographers, unappreciated by GPs, and variably managed by surgeons. These factors delay definitive therapy and seem to contribute to future biliary presentations. A fresh educational approach is required to raise awareness among radiologists, sonographers, and GPs regarding the clinical relevance and possible representations of GPL, and a uniform strategy is needed for managing GPL.

Abdominal pain and vomiting during pregnancy due to cholesterolosis

We present a 22-year-old pregnant woman at 15 weeks of gestation, with abdominal pain and vomiting. We demonstrate that diagnosis and treatment of vomiting and abdominal pain in pregnancy can be difficult. Therefore, involvement of other medical specialists is important when common treatments fail. Cholesterolosis can cause symptoms similar to those caused by cholelithiasis. Controversial to gallstones, identification of cholesterolosis by ultrasound is hard. Cholecystectomy is the only effective treatment option for cholesterolosis and can be performed safely during pregnancy. Cholecystectomy in pregnancy should be considered if, despite atypical symptoms, gallbladder disease is suspected and other diagnoses are ruled out. This may reduce recurrent symptoms, hospital admissions, exposure to harmful drugs and obstetric complications.

Ovo-lactovegetarian diet as a possible protective factor against gallbladder polyps in Taiwan: A cross-sectional study

Objective

Gallbladder polyps (GBPs) are an increasingly common incidental finding and 3% to 8% of GBPs become malignant. A poor prognosis is expected in patients with gallbladder cancer. No studies have considered the relationship between diet and the development of GBPs in the Taiwanese population. The objective of this study was to investigate whether a vegetarian diet protects against GBP development.

Materials and Methods

This cross-sectional study included 11,717 individuals who received a health checkup at Taipei Tzu Chi Hospital (New Taipei City, Taiwan) between October 2011 and October 2016. All individuals completed questionnaires that collected data about their characteristics, dietary patterns, and lifestyle. Physical examinations were conducted, and blood chemistry tests were performed. The presence of GBPs was determined using ultrasonography. We subsequently evaluated the association between diet and GBP prevalence using multivariate analysis.

Results

The prevalence of GBPs for the entire group was 8.3%. GBPs were significantly less common in the vegetarian groups (vegans 9.0%, ovo-lacto vegetarians 7.5%, and semi-vegetarians 7.2%) compared with the omnivore group (9.6%) (P = 0.002). Step-wise logistic regression revealed that an ovo-lacto vegetarian diet was a possible protective factor (odds ratio = 0.83, P = 0.015).

Conclusions

The study findings showed a strong negative association between an ovo-lacto vegetarian diet and GBP occurrence.

Transabdominal ultrasound and endoscopic ultrasound for diagnosis of gallbladder polyps

BACKGROUND

Approximately 0.6% to 4% of cholecystectomies are performed because of gallbladder polyps. The decision to perform cholecystectomy is based on presence of gallbladder polyp(s) on transabdominal ultrasound (TAUS) or endoscopic ultrasound (EUS), or both. These polyps are currently considered for surgery if they grow more than 1 cm. However, non-neoplastic polyps (pseudo polyps) do not need surgery, even when they are larger than 1 cm. True polyps are neoplastic, either benign (adenomas) or (pre)malignant (dysplastic polyps/carcinomas). True polyps need surgery, especially if they are premalignant or malignant. There has been no systematic review and meta-analysis on the accuracy of TAUS and EUS in the diagnosis of gallbladder polyps, true gallbladder polyps, and (pre)malignant polyps.

OBJECTIVES

To summarise and compare the accuracy of transabdominal ultrasound (TAUS) and endoscopic ultrasound (EUS) for the detection of gallbladder polyps, for differentiating between true and pseudo gallbladder polyps, and for differentiating between dysplastic polyps/carcinomas and adenomas/pseudo polyps of the gallbladder in adults.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, and trial registrations (last date of search 09 July 2018). We had no restrictions regarding language, publication status, or prospective or retrospective nature of the studies.

SELECTION CRITERIA

Studies reporting on the diagnostic accuracy data (true positive, false positive, false negative and true negative) of the index test (TAUS or EUS or both) for detection of gallbladder polyps, differentiation between true and pseudo polyps, or differentiation between dysplastic polyps/carcinomas and adenomas/pseudo polyps. We only accepted histopathology after cholecystectomy as the reference standard, except for studies on diagnosis of gallbladder polyp. For the latter studies, we also accepted repeated imaging up to six months by TAUS or EUS as the reference standard.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts, selected studies for inclusion, and collected data from each study. The quality of the studies was evaluated using the QUADAS-2 tool. The bivariate random-effects model was used to obtain summary estimates of sensitivity and specificity, to compare diagnostic performance of the index tests, and to assess heterogeneity.

MAIN RESULTS

A total of 16 studies were included. All studies reported on TAUS and EUS as separate tests and not as a combination of tests. All studies were at high or unclear risk of bias, ten studies had high applicability concerns in participant selection (because of inappropriate participant exclusions) or reference standards (because of lack of follow-up for non-operated polyps), and three studies had unclear applicability concerns in participant selection (because of high prevalence of gallbladder polyps) or index tests (because of lack of details on ultrasound equipment and performance). A meta-analysis directly comparing results of TAUS and EUS in the same population could not be performed because only limited studies executed both tests in the same participants. Therefore, the results below were obtained only from indirect test comparisons. There was significant heterogeneity amongst all comparisons (target conditions) on TAUS and amongst studies on EUS for differentiating true and pseudo polyps.Detection of gallbladder polyps: Six studies (16,260 participants) used TAUS. We found no studies on EUS. The summary sensitivity and specificity of TAUS for the detection of gallbladder polyps was 0.84 (95% CI 0.59 to 0.95) and 0.96 (95% CI 0.92 to 0.98), respectively. In a cohort of 1000 people, with a 6.4% prevalence of gallbladder polyps, this would result in 37 overdiagnosed and seven missed gallbladder polyps.Differentiation between true polyp and pseudo gallbladder polyp: Six studies (1078 participants) used TAUS; the summary sensitivity was 0.68 (95% CI 0.44 to 0.85) and the summary specificity was 0.79 (95% CI 0.57 to 0.91). Three studies (209 participants) used EUS; the summary sensitivity was 0.85 (95% CI 0.46 to 0.97) and the summary specificity was 0.90 (95% CI 0.78 to 0.96). In a cohort of 1000 participants with gallbladder polyps, with 10% having true polyps, this would result in 189 overdiagnosed and 32 missed true polyps by TAUS, and 90 overdiagnosed and 15 missed true polyps by EUS. There was no evidence of a difference between the diagnostic accuracy of TAUS and EUS (relative sensitivity 1.06, P = 0.70, relative specificity 1.15, P = 0.12).Differentiation between dysplastic polyps/carcinomas and adenomas/pseudo polyps of the gallbladder: Four studies (1,009 participants) used TAUS; the summary sensitivity was 0.79 (95% CI 0.62 to 0.90) and the summary specificity was 0.89 (95% CI 0.68 to 0.97). Three studies (351 participants) used EUS; the summary sensitivity was 0.86 (95% CI 0.76 to 0.92) and the summary specificity was 0.92 (95% CI 0.85 to 0.95). In a cohort of 1000 participants with gallbladder polyps, with 5% having a dysplastic polyp/carcinoma, this would result in 105 overdiagnosed and 11 missed dysplastic polyps/carcinomas by TAUS and 76 overdiagnosed and seven missed dysplastic polyps/carcinomas by EUS. There was no evidence of a difference between the diagnostic accuracy of TAUS and EUS (log likelihood test P = 0.74).

AUTHORS' CONCLUSIONS

Although TAUS seems quite good at discriminating between gallbladder polyps and no polyps, it is less accurate in detecting whether the polyp is a true or pseudo polyp and dysplastic polyp/carcinoma or adenoma/pseudo polyp. In practice, this would lead to both unnecessary surgeries for pseudo polyps and missed cases of true polyps, dysplastic polyps, and carcinomas. There was insufficient evidence that EUS is better compared to TAUS in differentiating between true and pseudo polyps and between dysplastic polyps/carcinomas and adenomas/pseudo polyps. The conclusions are based on heterogeneous studies with unclear criteria for diagnosis of the target conditions and studies at high or unclear risk of bias. Therefore, results should be interpreted with caution. Further studies of high methodological quality, with clearly stated criteria for diagnosis of gallbladder polyps, true polyps, and dysplastic polyps/carcinomas are needed to accurately determine diagnostic accuracy of EUS and TAUS.

Predictive Model for Neoplastic Potential of Gallbladder Polyp

GOAL

To provide the statistical predictive model for neoplastic potential of gallbladder polyp (GBP).

BACKGROUND

Many studies have attempted to define the risk factors for neoplastic potential of GBP. It remains difficult to precisely adapt the reported risk factors for the decision of surgery. Estimating the probability for neoplastic potential of GBP using a combination of several risk factors before surgical resection would be useful in patient consultation.

STUDY

We collected data of patients confirmed as GBP through cholecystectomy at Samsung Medical Center between January 1997 and March 2015. Those with a definite evidence for malignancy, such as adjacent organ invasion, metastasis on preoperative imaging studies, polyp >15 mm, and absence of proper preoperative ultrasonographic imaging were excluded. A total of 1976 patients were enrolled. To make and validate the predictive model, we divided the cohort into the modeling group (n=979) and validation group (n=997). Clinical information, ultrasonographic findings, and blood tests were retrospectively analyzed.

RESULTS

Clinical factors of older age, single lesion, sessile shape, and polyp size showed statistical significance for neoplastic potential of GBP in the modeling group. A predictive model for neoplastic potential of GBP was constructed utilizing the statistical outcome of the modeling group. Statistical validation was performed with the validation group to determine the optimal clinical sensitivity and specificity of the predictive model. Optimal cut-off value for neoplastic probability was 7.4%.

CONCLUSIONS

The predictive model for neoplastic potential of GBP may support clinical decisions before cholecystectomy.

Imaging of gall bladder by endoscopic ultrasound

Endoscopic ultrasonography (EUS) is considered a superior investigation when compared to conventional ultrasonography for imaging gall bladder (GB) lesions as it can provide high-resolution images of small lesions with higher ultrasound frequencies. Examination of GB is frequently the primary indication of EUS imaging. Imaging during EUS may not remain restricted to one station and multi-station imaging may provide useful information. This review describes the techniques of imaging of GB by linear EUS from three different stations. The basic difference of imaging between the three stations is that effective imaging from station 1 is done above the neck of GB, from station 2 at the level of the neck of GB and from station 3 below the level of the neck of GB.

The efficacy of real-time colour Doppler flow imaging on endoscopic ultrasonography for differential diagnosis between neoplastic and non-neoplastic gallbladder polyps

OBJECTIVES

We evaluated the usefulness of real-time colour Doppler flow (CDF) endoscopic ultrasonography (EUS) for differentiating neoplastic gallbladder (GB) polyps from non-neoplastic polyps.

METHODS

Between August 2014 and December 2016, a total of 233 patients with GB polyps who underwent real-time CDF-EUS were consecutively enrolled in this prospective study. CDF imaging was subjectively categorized for each patient as: strong CDF pattern, weak CDF pattern and no CDF pattern.

RESULTS

Of the 233 patients, 115 underwent surgical resection. Of these, there were 90 cases of non-neoplastic GB polyps and 23 cases of neoplastic GB polyps. In a multivariate analysis, a strong CDF pattern was the most significant predictive factor for neoplastic polyps; sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 52.2 %, 79.4 %, 38.7 %, 86.9 % and 73.9 %, respectively. Solitary polyp and polyp size were associated with an increased risk of neoplasm.

CONCLUSIONS

The presence of a strong CDF pattern as well as solitary and larger polyps on EUS may be predictive of neoplastic GB polyps. As real-time CDF-EUS poses no danger to the patient and requires no additional equipment, it is likely to become a supplemental tool for the differential diagnosis of GB polyps.

KEY POINTS

• Differential diagnosis between neoplastic polyps and non-neoplastic polyps of GB is limited. • The use of real-time CDF-EUS was convenient, with high agreement between operators. • The real-time CDF-EUS is helpful in differential diagnosis of GB polyps.

Risk stratification of gallbladder polyps larger than 10 mm using high-resolution ultrasonography and texture analysis

OBJECTIVES

To assess important features for risk stratification of gallbladder (GB) polyps >10 mm using high-resolution ultrasonography (HRUS) and texture analysis.

METHODS

We included 136 patients with GB polyps (>10 mm) who underwent both HRUS and cholecystectomy (non-neoplastic, n = 58; adenomatous, n = 32; and carcinoma, n = 46). Two radiologists retrospectively assessed HRUS findings and texture analysis. Multivariate analysis was performed to identify significant predictors for neoplastic polyps and carcinomas.

RESULTS

Single polyp (OR, 3.680-3.856) and larger size (OR, 1.450-1.477) were independently associated with neoplastic polyps (p < 0.05). In a single or polyp >14 mm, sensitivity for differentiating neoplastic from non-neoplastic polyps was 92.3%. To differentiate carcinoma from adenoma, sessile shape (OR, 9.485-41.257), larger size (OR, 1.267-1.303), higher skewness (OR, 6.382) and lower grey-level co-occurrence matrices (GLCM) contrast (OR, 0.963) were significant predictors (p < 0.05). In a polyp >22 mm or sessile, sensitivity for differentiating carcinomas from adenomas was 93.5-95.7%. If a polyp demonstrated at least one HRUS finding and at least one texture feature, the specificity for diagnosing carcinoma was increased to 90.6-93.8%.

CONCLUSION

In a GB polyp >10 mm, single and diameter >14 mm were useful for predicting neoplastic polyps. In neoplastic polyps, sessile shape, diameter >22 mm, higher skewness and lower GLCM contrast were useful for predicting carcinoma.

KEY POINTS

• Risk of neoplastic polyp is low in <14 mm and multiple polyps • A sessile polyp or >22 mm has increased risk for GB carcinomas • Higher skewness and lower GLCM contrast are predictors of GB carcinoma • HRUS is useful for risk stratification of GB polyps >1 cm.

Polypoid lesions of the gallbladder: analysis of 1204 patients with long-term follow-up

BACKGROUND

Polypoid lesions of the gallbladder (PLG) are common, and most are benign. Few lesions are found to be malignant, but are not preoperatively distinguished as such using common imaging modalities. Therefore, we compared characteristics of benign and malignant PLGs in depth.

METHODS

We enrolled 1204 consecutive patients diagnosed with PLG at Taipei Veterans General Hospital between January 2004 and December 2013. Patients underwent either surgery or regular follow-up with various imaging modalities for at least 24 months. The mean follow-up duration was 72 ± 32 months.

RESULTS

Of 1204 patients, 194 underwent surgical treatment and 1010, regular follow-up. In addition, 73 % patients were asymptomatic. The mean PLG size was 6.9 ± 7.7 (range 0.8-129) mm; the PLGs of 337 patients (28 %) grew during their follow-up periods. The majority of PLGs (90.4 %) were single lesions, and 10.5 % of patients had associated gallstones. The PLGs of 20.1 % of surgical patients were malignant. Malignant PLGs were found in 32.4 % of patients ≥50 years old and in 4.7 % of those <50 years old (p < 0.001). Right quadrant abdominal pain, epigastric pain, and body weight loss were the three most common symptoms associated with malignancy. Malignant PLGs were significantly larger than benign lesions (means: 27.5 ± 18.4 mm vs. 12.3 ± 12.3 mm, respectively, p < 0.001). Notably, the size of 5 % of malignant PLGs was 3-5 mm, and that of 8 % was 5-10 mm. The negative predictive value for gallbladder malignancy was 92.8 % based on a size ≥10 mm and 100 % based on a size ≥3 mm.

CONCLUSIONS

Our study reassesses the PLG size that warrants more aggressive intervention. Cholecystectomy remains mandatory for PLGs > 10 mm, but should also be considered a definitive diagnostic and treatment modality for PLGs with diameters of 3-10 mm.

Preoperative predictive factors for gallbladder cholesterol polyp diagnosed after laparoscopic cholecystectomy for polypoid lesions of gallbladder

BACKGROUNDS/AIMS

We investigated patients' clinical and radiological data to determine preoperative factors that predict cholesterol gallbladder (GB) polyps of large size, which can be helpful for decision on further diagnostic tools.

METHODS

In this study, we retrospectively analyzed 126 patients who underwent laparoscopic cholecystectomy for GB polyps >10 mm diagnosed preoperatively by abdominal ultrasonography between February 2002 and February 2016 in Department of Surgery, Sanggye Paik Hospital. Patients were divided into non-cholesterol polyps group and cholesterol polyps group, based on the postoperative pathologic diagnosis. Clinical and radiological data, such as gender, age, body weight, height, body mass index (BMI), laboratory findings, size, number and shape of the polypoid lesions, and presence of the concurrent GB stone were compared between the two groups.

RESULTS

Of the 126 cases, 73 had cholesterol polyps (57.9%) and 53 cases were non-cholesterol polyps (42.1%). The younger age (<48.5 years), size of polyp <13.25 mm and multiple polyps were independent predictive variables for cholesterol polyps, with odd ratios (OR) of 2.352 (p=0.045), 5.429 (p<0.001) and 0.472 (p<0.001), respectively.

CONCLUSIONS

Age, size and polyp number were used to predict cholesterol GB polyp among polypoid lesions of the gallbladder >10 mm. For cases in which these factors are not applicable, it is strongly recommended to evaluate further diagnostic tools, such as computed tomography, endoscopic ultrasonography and tumor markers.

Cholesterol polyps in the distal common bile duct: a case report

RATIONALE

Cholesterol polyps are rare in the common bile duct and difficult to diagnose.

PATIENT CONCERNS

The small polypoid lesions often go undetected when using routine imaging methods, such as ultrasonography.

DIAGNOSES

We treated a patient with cholesterol polyps in the common bile duct. After failing to detect choleliths using ultrasonography, magnetic resonance cholangiopancreatography revealed mild dilation of the common bile duct. Choledochoscopy was performed during laparoscopic cholecystectomy, which revealed yellowish-white polyps circumferentially distributed across the luminal surface of the distal common bile duct. Histological examination of biopsy specimens indicated cholesterol polyps with characteristic foamy cells.

INTERVENTIONS

The patient was treated with ursodeoxycholic acid, and the number of polyps was found to have been reduced at the 6-week follow-up based on T-tube choledochoscopic examination.

OUTCOMES

Recovery was unremarkable, and the ursodeoxycholic acid treatment was discontinued at the 6-month follow-up.

LESSONS SUBSECTIONS

Our findings suggest that this rare condition can be treated pharmacologically to avoid potential postsurgical complications following resection of the distal common bile duct.

Determinants for gallstone formation - a new data cohort study and a systematic review with meta-analysis

OBJECTIVE

Only few determinants of gallstone formation have been identified in cohort studies. The aim was to identify further determinants for gallstones in a Danish cohort and to perform a meta-analysis of results from existing cohorts.

MATERIAL AND METHODS

Data from a cohort study was used. Gallstone incidence was assessed through repeated ultrasound examinations. Body mass index (BMI), blood pressure, self-rated health, lifestyle variables, blood lipids, and use of female sex hormones were measured at the baseline examination. Statistical analyses included logistic regression. Based on a prospective protocol, a systematic review of the literature was performed identifying all articles dealing with determinants of incident gallstones. Meta-analyses of comparable determinants were performed through fixed effect models.

RESULTS

Participants with no gallstones at baseline and with at least one re-examination were followed-up completely (mean 11.6 years, N = 2848). The overall cumulative incidence of gallstones was 0.60% per year. Independent positive determinants for incident gallstones were age, female sex, non-high density lipoprotein (non-HDL) cholesterol, and gallbladder polyps. In addition, BMI was positively associated in men. The systematic review additionally identified associations for comorbidities, parity, and dietary factors. Meta-analysis confirmed the significant associations for incident gallstones and age, female sex, BMI, and non-HDL cholesterol. No significant associations were found for blood pressure, smoking, alcohol consumption, HDL cholesterol, or triglycerides in meta-analyses.

CONCLUSIONS

Age, female sex, BMI, non-HDL cholesterol, and polyps are independent determinants for gallstone formation. Incident gallstones and the metabolic syndrome share common risk factors. More studies are needed for further exploration.

Visceral Obesity Is Associated with Gallbladder Polyps

Background/Aims

Gallbladder polyps (GBP) are a common clinical finding and may possess malignant potential. We conducted this study to determine whether visceral obesity is a risk factor for GBP.

Methods

We retrospectively reviewed records of subjects who received both ultrasonography and computed tomography with measurements of the areas of visceral adipose tissue and total adipose tissue (TAT) on the same day as health checkups.

Results

Ninety-three of 1,615 subjects (5.8%) had GBP and were compared with 186 age- and sex-matched controls. VAT (odds ratio [OR], 2.941; 95% confidence interval [CI], 1.325 to 6.529; p=0.008 for the highest quartile vs the lowest quartile) and TAT (OR, 3.568; 95% CI, 1.625 to 7.833; p=0.002 for the highest quartile vs the lowest quartile) were independent risk factors together with hypertension (OR, 2.512; 95% CI, 1.381 to 4.569; p=0.003), diabetes mellitus (OR, 2.942; 95% CI, 1.061 to 8.158; p=0.038), hepatitis B virus positivity (OR, 3.548; 95% CI, 1.295 to 9.716; p=0.014), and a higher level of total cholesterol (OR, 2.232; 95% CI, 1.043 to 4.778; p=0.039 for <200 mg/dL vs ≥240 mg/dL). Body mass index and waist circumference were not meaningful variables.

Conclusions

Visceral obesity measured by VAT and TAT was associated with GBP irrespective of body mass index or waist circumference.

The role of endoscopic ultrasound in the diagnosis of gallbladder diseases

Endoscopic ultrasound (EUS) has recently played an increasing role in the diagnosis of gallbladder diseases. This review aims to summarize the role of EUS in the diagnosis of gallbladder lesions. EUS provides high-resolution images that can improve the diagnosis of gallbladder polypoid lesions and microlithiasis, in addition to evaluating gallbladder thickness and staging of gallbladder carcinoma. Contrast-enhancing agents may be useful for the differential diagnosis of gallbladder lesions, but the evidence of their effectiveness is still limited and further studies are required in this area to establish its usefulness. Endoscopic ultrasound combined with fine needle aspiration has played an increasing role in providing histological diagnosis of gallbladder tumors in addition to gallbladder thickening.

Intracholecystic papillary-tubular neoplasm in a patient with choledochal cyst: a link between choledochal cyst and gallbladder cancer?

BACKGROUND

Intracholecystic papillary-tubular neoplasms are rare precursor lesions of gallbladder cancer. They were proposed as a separate pathologic entity in 2012 by Adsay et al. for the unification of a variety of mass-forming precursor lesions including papillary adenomas, tubulopapillary adenomas, intestinal adenomas, and others. They are considered homologous to intrapapillary mucinous neoplasms of the pancreas and intrabiliary papillary neoplasms of the common bile duct. In contrast with the commoner flat-type precursor gallbladder cancer lesions, they follow a more indolent clinical course and probably different genetic pathways to carcinogenesis. They are largely uninvestigated with only a handful of studies providing biological and clinical information. Choledochal cysts are dilation of the common bile duct. Diagnosis is usually established during childhood, and only a minority of patients are diagnosed at adulthood. They are of major clinical importance as they are known predisposing factors for biliary carcinogenesis.

CASE PRESENTATION

The current report describes a patient with a simultaneous diagnosis of choledochal cyst and intracholecystic papillary-tubular neoplasm. The patient underwent excision of the extrahepatic biliary tree for a Todani I choledochal cyst, and histological examination of the specimen revealed an intracholecystic papillary-tubular neoplasm of the gallbladder. Authors describe diagnostic and clinical course of the patient alongside clinical and biological characteristics of these rare lesions.

CONCLUSIONS

To the best of our knowledge, this is the first report of a patient with a simultaneous diagnosis of choledochal cyst and intracholecystic papillary-tubular neoplasm. Those rare lesions shed light on different forms of gallbladder cancer carcinogenesis and its relationship with choledochal cysts and cholestasis.

The efficacy of contrast-enhanced harmonic endoscopic ultrasonography in diagnosing gallbladder cancer

The aim of this study was to review the efficacy of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) in diagnosing gallbladder (GB)-protruded lesions. Thirty-eight patients underwent CH-EUS for the diagnosis of GB-protruded lesions. Twenty-four patients whose major axes of their largest lesions were longer than 10 mm were recruited. The ability of CH-EUS to diagnose malignant or benign lesions was reviewed. We treated lesions with brindled enhanced patterns as malignant and those with uniformly enhanced or unenhanced patterns as benign. Furthermore, three gastroenterologists who were not familiar with pancreaticobiliary EUS compared the diagnostic abilities of CH-EUS and conventional EUS using photographs. The sensitivity, specificity, and malignant accuracy of CH-EUS were 100, 94.4, and 95.8%, respectively. The number of lesions that presented with enhanced patterns was significantly different between the malignant lesions and the benign lesions (P < 0.001). In the comparison of diagnostic abilities between CH-EUS and conventional EUS by the three gastroenterologists, CH-EUS was significantly superior to conventional EUS in terms of sensitivity, specificity, and accuracy (76.1 vs. 42.9%, P = 0.029; 66.7 vs. 39.2%, P = 0.005; and 69.4 vs. 40.3%, P < 0.001; respectively). In conclusion, CH-EUS was useful for diagnosing malignant and benign GB-protruded lesions.

Is it necessary to perform prophylactic cholecystectomy for all symptomatic gallbladder polyps diagnosed with ultrasound?

OBJECTIVE

The main aim of this study is to determine the necessity of cholecystectomy in patients with ultrasound diagnosed symptomatic polypoid lesions of the gallbladder.

MATERIAL AND METHODS

The data of 82 patients with polypoid lesions of the gallbladder who had cholecystectomy between 2000 and 2012 were analyzed retrospectively with preoperative ultrasound and histopathology results.

RESULTS

The mean age was 48.05±11.18 years (range 25-74 years). All patients underwent preoperative ultrasound examination. Eighteen (22%) of the 82 patients were asymptomatic; their polypoid lesions of the gallbladder were detected with ultrasound during a check-up or other reasons. In 45 (55%) of cases pathology reported no polypoid lesions of the gallbladder. Right upper quadrant or epigastric pain was the most common symptom (41.46%) that led to hepatobiliary ultrasound, the other symptom was dyspepsia (36.59%). On preoperative ultrasound evaluation, 22 patients had multiple polyps, and 9 of these 22 patients had at least 3 polyps.

CONCLUSION

There is an inaccuracy of ultrasound to detect polypoid lesions of the gallbladder. After diagnosing polypoid lesions of the gallbladder by using standard ultrasound, further pre-operative diagnostic tests are needed to help discriminating benign lesions from malignant ones, which may prevent unnecessary surgery regardless of symptoms.

Polypoid lesions of the gallbladder: disease spectrum with pathologic correlation

Gallbladder polyps are seen on as many as 7% of gallbladder ultrasonographic images. The differential diagnosis for a polypoid gallbladder mass is wide and includes pseudotumors, as well as benign and malignant tumors. Tumefactive sludge may be mistaken for a gallbladder polyp. Pseudotumors include cholesterol polyps, adenomyomatosis, and inflammatory polyps, and they occur in that order of frequency. The most common benign and malignant tumors are adenomas and primary adenocarcinoma, respectively. Polyp size, shape, and other ancillary imaging findings, such as a wide base, wall thickening, and coexistent gallstones, are pertinent items to report when gallbladder polyps are discovered. These findings, as well as patient age and risk factors for gallbladder cancer, guide clinical decision making. Symptomatic polyps without other cause for symptoms, an age over 50 years, and the presence of gallstones are generally considered indications for cholecystectomy. Incidentally noted pedunculated polyps smaller than 5 mm generally do not require follow-up. Polyps that are 6-10 mm require follow-up, although neither the frequency nor the length of follow-up has been established. Polyps that are larger than 10 mm are typically excised, although lower size thresholds for cholecystectomy may be considered for patients with increased risk for gallbladder carcinoma, such as patients with primary sclerosing cholangitis.

Evidence based management of polyps of the gall bladder: A systematic review of the risk factors of malignancy

BACKGROUND

There are no evidence-based guidelines to dictate when Gallbladder Polyps (GBPs) of varying sizes should be resected.

AIM

To identify factors that accurately predict malignant disease in GBP; to provide an evidence-based algorithm for management.

METHODS

A systematic review following PRISMA guidelines was performed using terms "gallbladder polyps" AND "polypoid lesion of gallbladder", from January 1993 and September 2013. Inclusion criteria required histopathological report or follow-up of 2 years. RTI-IB tool was used for quality analysis. Correlation with GBP size and malignant potential was analysed using Euclidean distance; a logistics mixed effects model was used for assessing independent risk factors for malignancy.

RESULTS

Fifty-three articles were included in review. Data from 21 studies was pooled for analysis. Optimum size cut-off for resection of GBPs was 10 mm. Probability of malignancy is approximately zero at size <4.15 mm. Patient age >50 years, sessile and single polyps were independent risk factors for malignancy. For polyps sized 4 mm-10 mm, a risk assessment model was formulated.

CONCLUSIONS

This review and analysis has provided an evidence-based algorithm for the management of GBPs. Longitudinal studies are needed to better understand the behaviour of polyps <10 mm, that are not at a high risk of malignancy, but may change over time.

Management and diagnosis of gallbladder polyps: a systematic review

PURPOSE

Recommendation for management of gallbladder polyps (GBPs) >1 cm is cholecystectomy. No consensus exists on management of GBPs <1 cm. This systematic review examines current evidence on management of GBPs.

METHODS

MEDLINE, EMBASE and Cochrane library databases were searched from January 1991 to June 2013 using specified terms. A predefined protocol for data extraction was used to retrieve specified end points.

RESULTS

Literature search yielded 43 manuscripts with a dataset of 11,685 patients with GBPs. M:F ratio was 1.3:1. Average age (range) was 49 years (32-83). Patients with malignant GBPs had an average (range) age of 58 (50-66) years with M:F ratio of 0.78:1. Cholesterol polyps constituted 60.5% of GBPs followed by adenomas (15.2%) and cancer (11.6%). Malignant GBPs ≥1 cm, <1 cm and <5 mm constituted 8.5, 1.2 and 0% of GBPs, respectively. Majority of patients requiring surgical intervention had laparoscopic cholecystectomy.

CONCLUSIONS

Presently employed policy of cholecystectomy for GBPs >1 cm is appropriate. For GBPs <1 cm, the authors propose (accepting existence of differing proposals) the following: 1. Surveillance may not be needed for GBPs <5 mm. 2. For GBPs between 5 and 10 mm, two scans at six monthly intervals is suggested and after that, tailor surveillance to age, growth and ethnicity. In the non-Asian population, if GBP remains the same size or number, discontinuation of surveillance may be considered. In the Asian population, if GBPs remain the same, yearly surveillance is continued for a suggested period of 3 years. 3. Discontinue surveillance if GBPs is/are smaller/ disappeared. Cholecystectomy is advised where size increases to >10 mm.

Polyp on Ultrasound: Now What? The Association between Gallbladder Polyps and Cancer

The association between gallbladder polyps (GBP) and gallbladder cancer (GBC) is unclear. We sought to determine the association between preoperative diagnosis of GBP on imaging and GBC. A retrospective review of patients over 9 years was conducted using International Classification of Diseases, 9th Revision codes for GBP and GBC who underwent cholecystectomy at our institution. Demographics, imaging findings, and pathology results were recorded. A total of 2416 patients underwent cholecystectomy during the study period. Twenty-seven had an operation for GBP either as a result of concern for size or symptoms. Polyp sizes were categorized as less than 1 cm, 1 to 2 cm, or 2 cm or greater. Twenty-four patients in this group (88.9%) had no evidence of high-grade dysplasia or cancer and all of these benign polyps were 2 cm or less on imaging. One patient with a 2.4-cm polyp had high-grade dysplasia, and two patients with polyps over 3 cm had adenocarcinoma. During the same period, 20 patients had an operation for GBC with two patients common to the polyp group. The group of patients with noncancerous polyps was significantly younger than the cancer group (polyps and no polyps). The cancer group was more likely to be symptomatic. Therefore, polyps over 2 cm should be removed given the risk of high-grade dysplasia and cancer above this size. Polyps less than 2 cm were not associated with high-grade dysplasia or cancer and thus surgery may not be required. Intermediate- and small-sized polyps can be monitored with serial ultrasound, especially in younger, asymptomatic patients in whom the risk of malignancy is low.