Asymptomatic Gall bladder pathology in a 40 year old lady

S Rajagopalan

A 40 year old female patient, apparently in good health, was referred to the surgical team from gynaecology. She had been admitted and investigated for perimenstrual lower abdominal pain. Her blood investigations were normal. Part of the evaluation protocol included an ultrasound of the abdomen and pelvis, the gynaecological organs being normal. However there was a mention of abnormality in the gall bladder identified incidentally.

The patient had planned a holiday to America in a few weeks and was very concerned at the mention of a problem in her gall bladder.

QUESTIONS:

1. What is the abnormality seen in the ultrasonogram of the gall bladder?
2. What is the diagnosis ?
3. How can one classify this group of conditions ?
4. What is an appropriate management protocol for these patients?

SELF ASSESSMENT ANSWERS

1) The lumen of the gall bladder has small rounded projections on its wall, seen both in the longitudinal and transverse sections

2) This group of conditions is referred to as Polypoidal Lesions of the Gall Bladder (PLG).

3) PLG can arise through many different pathologies. It has been classified by Christensen and Ishak 1 as follows:

4) Polyps in the gall bladder are detected in 4-5% of the population and most of them are benign. However, they can be premalignant and the prognosis for gall bladder carcinoma is still poor. The risk factors for malignancy were the age of the patient ( >60 years), the coexistence of gallstones, and the size of the polypoid lesions (>10 mm in diameter) 3. There have been various studies reported and a wide spectrum of treatment plans suggested, varying from wait and watch policy to early surgery after diagnosis.

However recent studies 2 say that in polyps less than 10 millimeters (maximum dimension), a regular follow up is enough with serial ultrasonograms.

All patients with a symptomatic PLG are offered a laparoscopic cholecystectomy. As the sensitivity of the sonogram is variable, asymptomatic patients are rescanned. If the rescan is negative the patient is discharged. If the rescan shows the persistence of the PLG, and the polyp size is <10 millimetre they are followed up once in every 6 months. If the size of the polyp is >10 millimetre then cholecystectomy is recommended.

In asymptomatic patients, cholecystectomy can be justified if there are risk factors for malignancy.

References

1. ChristensenAH, Ishak KG. Benign tumours and pseudotumours of the gall bladder. Report of 180 cases.Arch Pathol. 1970;90:423-32
2. Mainprize KS, Gould SW, Gilbert JM Surgical management of polypoid lesions of the gallbladder. Br J Surg. 2000 Apr;87(4):414-7.
3. Terzi C, Sokmen S, Seckin S, Albayrak L, Ugurlu M. Polypoid lesions of the gallbladder: report of 100 cases with special reference to operative indications. Surgery. 2000 Jun;127(6):622-7.