Cập nhật điều trị và theo dõi polyp túi mật

1. Ths.BS. ĐẶNG THỊ KIM LIÊN
dangthikimlien6368@gmail.com
GALLBLADDER POLYPS

2. Gallbladder (GB) polyps are defined as mucosal
projection of the GB wall into the lumen(1)
1. Christensen, AH %J Arch. Pathol. (1970), "Benign tumors and pseudotumors of the gallbladder.
Report of 180 cases". 90, pp. 423-432.

3. ☞ Surgery?
☞ Follow-up?

4. Gallbladder polyps
• Common benign lesion, 3 – 12,3% of the population(1)
• 3 - 7% of abdominal ultrasound examinations(2)
• 2 - 12% of cholecystectomy specimens (2)
• Only adenomatous harbor any malignant potential(1)
1. Courtney M. Townsend Jr., R. Daniel Beauchamp, B. Mark Evers, Kenneth L. Mattox - Sabiston Textbook of Surgery_ The Biological Basis of
Modern Surgical Practice-Elsevier (2021) p.1506
2. Jarnagin, W. R. (Ed.). (2022). Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 2-Volume Set-E-Book. Elsevier Health Sciences

5. Gallbladder polyps
In recent series of resected GB polyps,
< 20% were found to be adenomatous &
the rate of malignancy was around ≤ 5%
Michael Zinner, Stanley Ashley, O. Joe Hines - Maingot’s Abdominal Operations-McGraw-Hill Education
_ Medical (2018) p2997

6. Classification
Pseudopolyps: cholesterol polyps, focal
adenomyomatosis, hyperplastic polyps, inflammatory
polyps
True polyps:
+ Adenomas, adenocarcinomas
+ Rare types: mesenchymal tumours, lymphoma,
metastases
1. Courtney M. Townsend Jr., R. Daniel Beauchamp, B. Mark Evers, Kenneth L. Mattox - Sabiston Textbook of Surgery_ The Biological
Basis of Modern Surgical Practice-Elsevier (2021) p.1506
2. Wiles, Rebecca, et al. (2017), "Management and follow-up of gallbladder polyps". 27(9), pp. 3856-3866.

7. McCain, R Stephen, et al. (2018), "Current practices and future prospects for the management of gallbladder
polyps: a topical review". 24(26), p. 2844.]
Gallbladder
polyps
Pseudopolyps
Cholesterol
polyps
Focal
adenomyomatosis
Hyperplastic
polyps
Inflammatory
polyps
True polyps
Adenomas Adenocarcinomas
Classification

8. Classification
Nonneoplastic polyps: cholesterol polyps
(60–90%), adenomyomas (25%–40%),
inflammatory polyps (10%), fibromyoglandular
Neoplastic polyps: adenomas,
intracholecystic papillary neoplasms,
adenocarcinoma
Kim, Kook Hyun %J Yeungnam University Journal of Medicine (2021), "Gallbladder polyps: evolving approach to the
diagnosis and management". 38(1), p. 1.

9. Nonneoplastic polyps

10. Neoplastic polyps

11. Kim, Kook Hyun %J Yeungnam University Journal of Medicine (2021), "Gallbladder polyps: evolving approach to the
diagnosis and management". 38(1), p. 1.

12. Rokitansky – Aschoff sinuses
• 2 pathologists: Baron Karl Freiherr von Rokitansky
(1804-1878) & Karl Albert Ludwig Aschoff (1866-1942)
• Histologically, outpouchings of GB mucosa sit within
the GB muscle layer
• Associated with cholecystitis & adenomyomatosis
• Mimic GB adenocarcinoma
• Generally incidental findings
https://radiopaedia.org/articles/rokitansky-aschoff-sinuses

13. Adenomyomatosis Rokitansky – Aschoff sinuses
https://radiopaedia.org/articles/rokitansky-aschoff-sinuses

14. Courtney M. Townsend Jr., R. Daniel Beauchamp, B. Mark Evers, Kenneth L. Mattox - Sabiston Textbook of Surgery_ The
Biological Basis of Modern Surgical Practice-Elsevier (2021) p.1506

15. Presentations
• Most patients: asymptomatic
• Nonspecific gastric symptoms (nausea, vomiting, right
hypochondriac pain)
• Rarely, large polyps may obstruct the cystic duct
causing acute cholecystitis or obstructive jaundice
• 64% found incidentally on workup done, 23%
presented with abdominal symptoms, 13% had raised
liver function tests.
Kalbi, Deepak P., et al. (2021), "Surveillance of Gallbladder Polyps: A Literature Review", Cureus. 13(7),
pp. e16113-e16113.

16. Radiological imaging
1. McCain, R Stephen, et al. (2018), "Current practices and future prospects for the management of gallbladder
polyps: a topical review". 24(26), p. 2844.]
2. Kim, Kook Hyun %J Yeungnam University Journal of Medicine (2021), "Gallbladder polyps: evolving approach
to the diagnosis and management". 38(1), p. 1.

17. Radiological imaging
Ultrasonography
• Hyperechoic lesions protruding into the GB lumen
• Absence of post-acoustic shadow
• A fixed lesion helps to distinguish between polyps and
gallstones
• “Pseudo” polyp include a “comet tail” which arises
posterior to the lesion but not in all

18. Kim, Kook Hyun %J Yeungnam University Journal of Medicine (2021), "Gallbladder polyps: evolving approach
to the diagnosis and management". 38(1), p. 1.

19. Wiles, Rebecca, et al. (2017), "Management and follow-up of gallbladder polyps". 27(9), pp. 3856-3866.

20. Radiological imaging
Endoscopic ultrasound
• Greater sensitivity (67% & 86%) & specificity (84%
& 91%) for diagnosing malignancy in polyps
• An invasive examination associated with a small
risk of bleeding & upper gastrointestinal perforation

21. Radiological imaging
Computed tomography
• First-line modality for symptomatic patients
• Best used in staging larger, suspicious
malignant polyps, rather than for diagnostic
purposes and follow up

22. Radiological imaging
Magnetic resonance imaging
• selful in the evaluation of tumor infiltration
Other imaging modalities
• positron emission tomography (PET): inflammatory GB lesions
can show false-positive
• fluorine-18-labeled fluorodeoxyglucose (18F-FDG)
• percutaneous transhepatic cholecystoscopy
• Intravenous cholecystography

23. Surgery?

24. ESGAR/EAES/EFISDS/ESGE Guidelines for
Gallbladder Polyps
2017 & 2021
• The European Society of Gastrointestinal and Abdominal Radiology (ESGAR)
• The European Association for Endoscopic Surgery and other Interventional
Techniques (EAES)
• The International Society of Digestive Surgery–European Federation (EFISDS)
• The European Society of Gastrointestinal Endoscopy (ESGE)

25. ESGAR/EAES/EFISDS/ESGE Guidelines for Gallbladder Polyps
2017 2021
1
Cholecystectomy if
patient is fit for &
accepts surgery
Polypoid lesion ≥ 10 mm Polypoid lesion ≥ 10 mm
2
Symptoms + no alternative cause for the
patient’s symptoms
Symptoms + no alternative cause for the
patient’s symptoms
Regarding the benefit of cholecystectomy vs the
risk of persistent symptoms
3 6 – 9 mm + risk factors 6 – 9 mm + risk factors
4
During follow-up gallbladder polyp reaches 10
mm
During follow-up gallbladder polyp reaches 10
mm
Grows by ≥ 2 mm
Risk factor
• Age > 50
• PSC
• Indian ethnicity
• Sessile polyp (including focal GB wall
thickening >4 mm)
• Others: solitary polyps, East Asians, presence
of gallstones
• Age > 60
• PSC
• Asian ethnicity
• Sessile polyp (including focal GB wall
thickening >4 mm)

26. ESGAR/EAES/EFISDS/ESGE Guidelines for Gallbladder Polyps
2017 2021
5
6 – 9 mm + no risk factors
Follow-up US at 6 months, 1 year and
then yearly up to 5 years
Follow-up US at 6 months, 1 year 2
years
Discontinue after 2 years in the
absence of growth
≤ 5 mm + risk factors
6 ≤ 5 mm + no risk factors
Follow-up is advised at 1 year, 3 years
and 5 years
Follow-up is not required
7 During follow-up GB polyp disappears Discontinue follow-up Discontinue follow-up
8
- Primary investigation should be with
TAUS
- Endoscopic ultrasound) may be
useful to aid decision-making in
difficult cases
- Primary investigation should be with
TAUS
- Endoscopic ultrasound) may be
useful to aid decision-making in
difficult cases

27. Reasons for lap.cholecystectomy
(1) The overall low risk of malignancy
(2) Simple cholecystectomy is curative for T1a tumors
(3) Lap. resected early-stage tumors do not appear to have
a worse outcome if a definitive resection is performed
subsequently & there is no perforation of the GB
William R. Jarnagin (Auth.) - Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 2-Volume Set- Elsevier (2016), p796

28. Why don’t GB polyps always require
surgery?
Associated with several complications
• Bile duct injury
• Bile leak
• Damage to intra-abdominal structures
• The ultimate treatment for “true” GB polyps
Kalbi, Deepak P., et al. (2021), "Surveillance of Gallbladder Polyps: A Literature Review", Cureus. 13(7), pp.
e16113-e16113.

29. References
1. Christensen, AH %J Arch. Pathol. (1970), "Benign tumors and pseudotumors of the
gallbladder. Report of 180 cases". 90, pp. 423-432.
2. Kim, Kook Hyun %J Yeungnam University Journal of Medicine (2021), "Gallbladder
polyps: evolving approach to the diagnosis and management". 38(1), p. 1.
3. McCain, R Stephen, et al. (2018), "Current practices and future prospects for the
management of gallbladder polyps: a topical review". 24(26), p. 2844.
4. Wiles, Rebecca, et al. (2017), "Management and follow-up of gallbladder polyps",
European Radiology. 27(9), pp. 3856-3866.

30. References
5. Kalbi, Deepak P., et al. (2021), "Surveillance of Gallbladder Polyps: A Literature Review", Cureus.
13(7), pp. e16113-e16113.
6. Courtney M. Townsend Jr., R. Daniel Beauchamp, B. Mark Evers, Kenneth L. Mattox - Sabiston
Textbook of Surgery_ The Biological Basis of Modern Surgical Practice-Elsevier (2021) p.1506
7. Michael Zinner, Stanley Ashley, O. Joe Hines - Maingot’s Abdominal Operations-McGraw-Hill
Education _ Medical (2018) p2997
8. Christensen, AH %J Arch. Pathol. (1970), "Benign tumors and pseudotumors of the gallbladder.
Report of 180 cases". 90, pp. 423-432.
9. https://radiopaedia.org/articles/rokitansky-aschoff-sinuses
10. Schwartz’s principles of surgery, 11e (2019) – p1421

31. Thank you!