Incidental Gallbladder Polyps – A Case Report on Diagnostic Dilemmas and Management Uncertainty

Abstract

Incidental findings of the gallbladder and bile ducts are common results in routine ultrasound examinations. This highlights the importance of accurate diagnostics and risk stratification to guide clinical decision-making appropriately. This case report discusses the diagnostic and therapeutic challenges posed by incidental gallbladder polyps (GBPs) through the case of a young man in his late twenties, in whom multiple polyps in the gallbladder were discovered during an abdominal ultrasound. Following current clinical guidelines, he underwent an elective cholecystectomy. The histopathological examination showed no signs of malignancy, emphasizing the ongoing challenge of correctly identifying suspicious lesions while avoiding unnecessary procedures or overtreatment. The case illustrates the limitations of imaging techniques, particularly in assessing the malignancy risk of polyps. It also highlights the variability in size measurements and the need for a nuanced, interdisciplinary decision-making process. Finally, the case raises important questions about patient-centered care, as individual perspectives often differ from standardized recommendations.

Zusammenfassung

Zufallsbefunde der Gallenblase und der Gallenwege sind häufig. Dies hebt die Bedeutung einer präzisen Diagnostik und Risikostratifizierung hervor, um klinische Entscheidungen richtig zu treffen. Dieser Fallbericht beschreibt die diagnostischen und therapeutischen Herausforderungen bei inzidentellen Gallenblasenpolypen (GBPs), anhand des Falles eines jungen Mannes, bei dem im Rahmen einer Sonografie des Abdomens mehrere Polypen in der Gallenblase entdeckt wurden. Entsprechend der aktuellen klinischen Leitlinien erfolgte eine elektive Cholezystektomie. Die histopathologische Untersuchung ergab keinen Hinweis auf Malignität und verdeutlicht damit die Herausforderung, verdächtige Veränderungen korrekt zu identifizieren, ohne unnötige Eingriffe vorzunehmen. Der Fall zeigt die Grenzen bildgebender Verfahren auf, insbesondere in Bezug auf die Einschätzung des malignen Potenzials von GBP. Auch die Variabilität bei der Messung der Polypengröße und die Notwendigkeit einer differenzierten, interdisziplinären Entscheidungsfindung werden verdeutlicht. Letztendlich wirft der Fall wichtige Fragen zur patientenzentrierten Versorgung auf, da individuelle Perspektiven von standardisierten Empfehlungen abweichen können.

Summary Statements

• Incidental findings of the gallbladder (IFGB) are common, and most IFGB are benign with no malignant potential.

• Differentiation between neoplastic and non-neoplastic polyps is a challenging but essential part in risk assessment.

• Many factors might affect assessment of GBP size on ultrasound imaging (artifact formation, discrepancies between pre-, intra- and postoperative findings, inter- and intra-observer variability).

• Unnecessary imaging in low-risk populations can lead to unnecessary interventions, adversely affecting health outcomes and healthcare costs.

• Clinical decision should thus include individual risk assessment through multidisciplinary discussion.

• CEUS may offer additional diagnostic information but requires considerable expertise. CEUS enhancement can be seen in neoplastic as well as in non-neoplastic polyps.

• Patientʼs perspective may differ to standardized recommendations.

Keywords

Incidental finding - gallbladder polyp - cholesterol polyp - denomyomatosis - contrast enhanced ultrasound (CEUS) - cholecystectomy

Schlüsselwörter

Zufallsbefund - Gallenblasenpolyp - Cholesterinpolyp - Adenomyomatose - Kontrastmittelverstärkter Ultraschall - Cholezystektomie

Publication History

Received: 11 April 2025

Accepted after revision: 13 June 2025

Article published online:
16 July 2025

• References

• 1 Foley KG, Lahaye MJ, Thoeni RF. et al. Management and follow-up of gallbladder polyps: updated joint guidelines between the ESGAR, EAES, EFISDS and ESGE. Eur Radiol 2022; 1: 1-11
• 2 Jenssen C, Lorentzen T, Dietrich CF. et al. Incidental Findings of Gallbladder and Bile Ducts – Management Strategies: General Aspects, Gallbladder Polyps and Gallbladder Wall Thickening – A WFUMB Position Paper. Ultrasound Med Biol 2022; 48: 2355-2378
• 3 Riddell ZC, Corallo C, Albazaz R. et al. Gallbladder polyps and adenomyomatosis. Br J Radiol 2023; 96: 20220115
• 4 Szpakowski J-L, Tucker L-Y. Outcomes of gallbladder polyps and their association with gallbladder cancer in a 20-year cohort. JAMA Netw Open 2020; 3: e205143-e205143
• 5 Myers RP, Shaffer EA, Beck PL. Gallbladder polyps: epidemiology, natural history and management. Can J Gastroenterol Hepatol 2002; 16: 187-194
• 6 Holanda AKG, Lima Júnior ZB. Gallbladder histological alterations in patients undergoing cholecystectomy for cholelithiasis. Rev Col Bras Cir 2020; 46: e20192279
• 7 Andrén-Sandberg Å. Diagnosis and management of gallbladder polyps. N Am J Med Sci 2012; 4: 203
• 8 Taskin OC, Bellolio E, Dursun N. et al. Non-neoplastic polyps of the gallbladder: a clinicopathologic analysis of 447 cases. Am J Surg Pathol 2020; 44: 467-476
• 9 Kim KH. Gallbladder polyps: evolving approach to the diagnosis and management. Yeungnam Univ J Med 2021; 38: 1-9
• 10 Sugiyama M, Atomi Y, Yamato T. Endoscopic ultrasonography for differential diagnosis of polypoid gall bladder lesions: analysis in surgical and follow up series. Gut 2000; 46: 250-254
• 11 Jenssen C, Tuma J, Moller K. et al. Ultrasound artifacts and their diagnostic significance in internal medicine and gastroenterology – part 2: color and spectral Doppler artifacts. Z Gastroenterol 2016; 54: 569-578
• 12 Tuma J, Jenssen C, Moller K. et al. Ultrasound artifacts and their diagnostic significance in internal medicine and gastroenterology – Part 1: B-mode artifacts. Z Gastroenterol 2016; 54: 433-450
• 13 Golse N, Lewin M, Rode A. et al. Gallbladder adenomyomatosis: Diagnosis and management. J Visc Surg 2017; 154: 345-353
• 14 Liu X-S, Gu L-H, Du J. et al. Differential Diagnosis of Polypoid Lesions of the Gallbladder Using Contrast-Enhanced Sonography. J Ultrasound Med 2015; 34: 1061-1069
• 15 Kratzer W, Mason RA, Kächele V. Prevalence of gallstones in sonographic surveys worldwide. J Clin Ultrasound 1999; 27: 1-7
• 16 Okamoto M, Okamoto H, Kitahara F. et al. Ultrasonographic evidence of association of polyps and stones with gallbladder cancer. Am J Gastroenterol 1999; 94: 446-450
• 17 Taskin OC, Basturk O, Reid MD. et al. Gallbladder polyps: Correlation of size and clinicopathologic characteristics based on updated definitions. PLoS One 2020; 15: e0237979
• 18 Spârchez Z, Radu P. Role of CEUS in the diagnosis of gallbladder disease. Med Ultrason 2012; 14: 326-330
• 19 Sidhu PS, Cantisani V, Dietrich CF. et al. The EFSUMB Guidelines and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound (CEUS) in Non-Hepatic Applications: Update 2017 (Long Version). Ultraschall Med 2018; 39: e2-e44
• 20 Sidhu PS, Cantisani V, Dietrich CF. et al. The EFSUMB Guidelines and Recommendations for the Clinical Practice of Contrast-Enhanced Ultrasound (CEUS) in Non-Hepatic Applications: Update 2017 (Short Version). Ultraschall Med 2018; 39: 154-180
• 21 Zheng S-G, Xu H-X, Liu L-N. et al. Contrast-enhanced ultrasound versus conventional ultrasound in the diagnosis of polypoid lesion of gallbladder: a multi-center study of dynamic microvascularization. Clin Hemorheol Microcirc 2013; 55: 359-374
• 22 Bae JS, Kim SH, Kang H-j. et al. Quantitative contrast-enhanced US helps differentiating neoplastic vs non-neoplastic gallbladder polyps. Eur Radiol 2019; 29: 3772-3781
• 23 Chang W, Lee S, Kim YY. et al. Interpretation, Reporting, Imaging-Based Workups, and Surveillance of Incidentally Detected Gallbladder Polyps and Gallbladder Wall Thickening: 2025 Recommendations From the Korean Society of Abdominal Radiology. Korean J Radiol 2025; 26: 102-134
• 24 Cheng R, Dong Y. Comparison of Recommendations for Gallbladder Polyps and Gallbladder Wall Thickening Between KSAR and WFUMB Guidelines. Korean J Radiol 2025; 26: 508-510
• 25 Kamaya A, Fung C, Szpakowski J-L. et al. Management of incidentally detected gallbladder polyps: society of radiologists in ultrasound consensus conference recommendations. Radiology 2022; 305: 277-289
• 26 Stewart C, Davenport MS, Miglioretti DL. et al. Types of evidence needed to assess the clinical value of diagnostic imaging. N Engl J Evid 2024; 3: EVIDra2300252
• 27 Wennmacker SZ, de Savornin Lohman EA, Hasami NA. et al. Overtreatment of nonneoplastic gallbladder polyps due to inadequate routine ultrasound assessment. Dig Surg 2021; 38: 73-79
• 28 Thammaroj J, Ungarreevittaya P, Jenwitheesuk K. Does gallbladder polyp size as measured using radiographic modalities predict pathological size in all types of polyps?. Rep Med Imaging 2018; 27-30
• 29 Lee K-C, Kim J-K, Kim D-K. Comparison of the Size Measurement of Gallbladder Polyps by Three Different Radiologists in Abdominal Ultrasonography. Tomography 2024; 10: 1031-1041
• 30 Lee SB, Lee Y, Kim SJ. et al. Intraobserver and interobserver reliability in sonographic size measurements of gallbladder polyps. Eur Radiol 2020; 30: 206-212
• 31 Walas MK, Skoczylas K, Gierbliński I. Errors and mistakes in the ultrasound diagnostics of the liver, gallbladder and bile ducts. J Ultrason 2012; 12: 446
• 32 Hindi A, Peterson C, Barr RG. Artifacts in diagnostic ultrasound. Rep Med Imaging 2013; 29-48
• 33 Jenssen C, Nolsøe CP, Lorentzen T. et al. Incidental findings of gallbladder and bile ducts – Management strategies: Normal findings, anomalies, “silent gallstones” and bile duct dilatation – A World Federation of Ultrasound in Medicine and Biology (WFUMB) position paper. WFUMB Ultrasound Open 2024; 2: 100034