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Gallstones & Gallbladder Polyps

 

This guidance applies to adults

 

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)

  • Fast track referral for patients with suspected gallbladder carcinoma on USS

 

Cholecystectomy is commissioned where patients meet the criteria below

  • Symptomatic gallbladder stones
  • Asymptomatic common bile duct (CBD) stones (for consideration of bile duct clearance and laparoscopic cholecystectomy)
  • Patients with dilated CBD without stones
  • Confirmed episode of gallstone induced pancreatitis
  • Confirmed episode of cholecystitis
  • Episode of obstructive jaundice caused by biliary calculi
  • Where there is clear evidence of patients being at risk of gallbladder complications
  • Biliary dyskinesia
  • Where there is clear evidence of patients being at risk of gallbladder carcinoma (for example porcelain gallbladder)

Asymptomatic gallstones outside the CBD do not need to be referred

 

Gallbladder polyps

  • Symptomatic gallbladder polyps OR
  • Polyp ≥10mm size OR
  • Polyps associated with risk factors for malignancy, for instance:
    • Age >60 years old
    • Primary sclerosing cholangitis (PSC)
    • Asian ethnicity
    • Sessile polypoid lesion, including focal wall thickening >4mm
  • A polyp demonstrating rapid growth, eg growing 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

  • Cholecystectomy.  Cornwall and IoS Commissioning Policy and Evidence Based Interventions, April 2025.
  • Gallstones Clinical Knowledge Summaries.  National Institute Of Clinical Excellence, June 2024

 

Page Review Information

Review Date                      13 May 2025 (partial update)

Next Review Date              13 May 2026

GP Sifter                             Dr Laura Lomas,

                                            Dr Laura Vines

Contributor                          Mr Mike Clarke,

       Mr Paul Peyser