MKSAP quiz: Follow-up after hospitalization for right flank pain
A 53-year-old woman is evaluated in follow-up after a recent hospitalization for right flank pain.
A 53-year-old woman is evaluated in follow-up after a recent hospitalization for right flank pain. Ultrasound performed in the hospital showed a dilated right renal collecting system and a 12-mm gallbladder polyp. Two hours after admission, she passed a stone in the urine and the right flank pain resolved. Since her hospitalization, she has had no other episodes of pain and otherwise feels well.
On physical examination, vital signs are normal; BMI is 34. Abdominal examination reveals a normal liver and spleen, no tenderness, and a negative Murphy sign.
Laboratory studies, including a complete blood count, alkaline phosphatase, alanine aminotransferase, and bilirubin, are normal.
Which of the following is the most appropriate management?
A. Abdominal CT
B. Cholecystectomy
C. Endoscopic retrograde cholangiopancreatography
D. Magnetic resonance cholangiopancreatography
E. Ultrasound in 1 year
MKSAP Answer and Critique
The correct answer is B. Cholecystectomy. This item is available to MKSAP 17 subscribers as item 17 in the Gastroenterology & Hepatology section. More information about MKSAP 17 is available online.
The most appropriate management is cholecystectomy. The finding of a gallbladder polyp larger than 1 cm is an indication for cholecystectomy, even if the patient is asymptomatic. Gallbladder polyps are found in approximately 5% of ultrasound examinations. Although only a small percentage of gallbladder polyps are neoplastic (adenoma or adenocarcinoma), the risk for neoplasia increases as polyp size increases. In the absence of gallstones, a gallbladder polyp smaller than 1 cm can be followed with serial ultrasound examinations unless the patient is symptomatic or has primary sclerosing cholangitis. For patients with gallstones and any size polyp, cholecystectomy is usually recommended.
Further imaging with abdominal CT, endoscopic retrograde cholangiopancreatography, or magnetic resonance cholangiopancreatography is not necessary in this patient because she has an asymptomatic, incidental gallbladder polyp; however, these tests should be considered if this patient had symptoms or elevated liver chemistry tests suggesting bile duct obstruction or malignancy.
Key Point
- The finding of a gallbladder polyp larger than 1 cm is an indication for cholecystectomy, even if the patient is asymptomatic.