Initial assessment
When a gallbladder polyp is identified, the first step is to distinguish an incidental finding from a situation in which there are symptoms potentially attributable to the gallbladder, such as biliary colic or associated complications. The polypoid nature of the lesion should be confirmed and differential diagnoses excluded, with careful assessment of size, morphology (sessile or pedunculated) and the presence of focal gallbladder wall thickening. Most polyps are benign, but a small proportion have neoplastic potential, justifying a systematic approach.
Differential diagnosis
Before defining a surveillance or treatment strategy, it is essential to exclude entities that may mimic true polyps. These include gallbladder adenomyomatosis, tumefactive sludge and focal inflammatory changes of the wall. Adequate imaging characterization is essential to avoid prolonged follow-up or unnecessary surgery for benign lesions.
Risk stratification
The risk of malignancy depends mainly on polyp size and is modified by clinical and imaging risk factors. Relevant risk factors include primary sclerosing cholangitis, age over 60 years, Asian ethnicity and sessile morphology or focal gallbladder wall thickening > 4 mm. The presence of at least one risk factor may significantly change clinical decision-making.
Management of polyps ≥10 mm
Polyps measuring 10 mm or more are associated with an increased risk of malignancy and, in most cases, justify cholecystectomy. In very large lesions, particularly those ≥20 mm, priority referral should be considered, along with additional imaging assessment for staging before a definitive surgical decision.
Management of 6–9 mm polyps
For intermediate-sized polyps, the strategy depends on the presence of risk factors. In the absence of risk factors, imaging surveillance is recommended. When at least one risk factor for malignancy is present, cholecystectomy should be considered, ideally after multidisciplinary assessment and discussion with the patient.
Management of polyps ≤5 mm
Small polyps have a very low risk of malignant transformation. In the absence of risk factors, no follow-up is required. If at least one relevant risk factor is present, ultrasound surveillance is recommended, following the same schedule used for intermediate-sized polyps without risk factors.
Imaging surveillance
When indicated, surveillance is usually performed with ultrasound at 6, 12 and 24 months. If the polyp remains stable for two years, follow-up may be discontinued. Disappearance of the lesion does not require further surveillance.
Growth during surveillance
An increase ≥2 mm during the surveillance period should prompt clinical reassessment, taking into account current size and risk factors. If the polyp reaches ≥10 mm or if the overall risk profile is high, surgical decision-making should be considered.
Special situations
In patients with primary sclerosing cholangitis, the risk of gallbladder carcinoma is higher and management should be individualized, preferably in coordination with Gastroenterology or Hepatology. In these cases, the threshold for surveillance or surgery may be lower than in the general population.
Follow-up and safety
Interpretation of gallbladder polyps should integrate clinical, imaging and evolutionary data, avoiding decisions based on a single isolated examination. A structured approach allows early identification of high-risk lesions, while reassuring most patients with benign findings, promoting safe, rational clinical practice aligned with current evidence.
