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Gallstones & Gallbladder Polyps

 

Background

Gallstones are common and occur when there is a problem relating to the chemical composition of bile. Most people with gallstone disease are asymptomatic and will remain asymptomatic. However, each year about 2-4% previously asymptomatic patients develop symptoms or complications.

The two most common complications are biliary colic, followed by acute cholecystitis. Other complications are rare, but some are life-threatening such as cholangitis (fever/rigors, jaundice, RUQ pain) and pancreatitis.

Gallbladder polyps are a common finding at abdominal ultrasound. Their management remains contentious. Current guidelines aim to identify those most at risk of progression to malignancy and those in whom ultrasound surveillance or surgery are recommended.

 

Referral criteria

Criteria for same day discussion with general surgeon on-call:

  • Systemically unwell with complications of gallbladder disease, i.e. acute cholecystitis, cholangitis or pancreatitis
     
  • Known gallstones and jaundice
     
  • Clinical suspicion of biliary obstruction i.e. significantly deranged LFTs
     


Criteria for routine or urgent referral to Upper GI surgery (depending on clinical judgement):

Gallstones

  • Stones found on imaging and causing symptoms, within the last 12 months
     
  • Asymptomatic gallstones found in the CBD (for consideration of bile duct clearance and laparoscopic cholecystectomy)

Asymptomatic gallstones outside the CBD do not need to be referred


Gallbladder polyps

  • Symptoms attributable to gallbladder OR

  • Polyp ≥10mm size OR

  • Polyp 6-9mm AND one or more risk factors for malignancy:
    • Age >60 years old
    • Primary sclerosing cholangitis (PSC)
    • Asian ethnicity
    • Sessile polypoid lesion, including focal wall thickening >4mm
  • If a polyp grows by 2mm or more within a 2-year follow-up or reaches 10mm

 

All others, please see flowchart below regarding surveillance interval and ongoing management of gallbladder polyps:

 

 

Investigations prior to referral

  • LFTs
  • Abdominal USS (please attach results to referral)

 

Management of suspected retained stones after gallbladder surgery

  • LFTs and amylase
  • Urgent USS
  • Depending on clinical urgency, referral to jaundice clinic or if systemically unwell, discuss with Upper GI surgeon on-call via switch. MRCP and ERCP will then be arranged.

Nb. A dilated CBD post gallbladder surgery on its own is quite common after surgery and not necessarily suggestive of a retained stone.

 

 

References

https://cks.nice.org.uk/topics/gallstones/

 

 

Review Date                           November 2023

Next Review Date                   November 2024

GP Sifter                                 Dr Laura Vines

Contributor                              Mr Mike Clarke

                                                Mr Paul Peyser

Version                                    3.0