Gallbladder polyps
Introduction
Introduction to gallbladder polyps Polypofgallbladder refers to a type of lesion in which the gallbladder wall is a polypoid-like bulge in the cystic cavity. Also known as polypoidlesion of gallbladder (PLG). Gallbladder polypoid lesions can be divided into benign or malignant lesions, but non-neoplastic lesions are more common. It is generally believed that gallbladder polypoid lesions with a diameter of more than 15 mm are almost all malignant tumors. Therefore, polypoid lesions of the gallbladder have been paid more attention in recent years. basic knowledge The proportion of sickness: 0.2% Susceptible people: no specific people Mode of infection: non-infectious Complications: gallbladder cancer
Cause
Causes of gallbladder polyps
Causes
The etiology of gallbladder polypoid lesions is still unclear, but it is generally believed that the occurrence of this disease is closely related to chronic inflammation. Inflammatory polyps and adenomyosis are an inflammatory reactive disease, and cholesterol polyps are systemic fat. As a result of metabolic disorders and local inflammation of the gallbladder, it has been suggested that gallbladder polyps are associated with gallbladder inflammation or calculus, or even both.
Pathogenesis
PLG is a group of biliary diseases with the same expression but many different pathological conditions. The pathological classification is divided into two categories: non-tumor lesions and neoplastic lesions. The latter is divided into good and malignant.
Non-neoplastic PLG
(1) Cholesterol polyps: Cholesterol polyps (CPs) are the most common in non-neoplastic lesions. Wolpers observed 181 cases of PLG for 9.5 years, 95% of which were CPs, and Kubota group of CPs accounted for 65%. Domestic Yang Hanliang, statistics There were 179 cases of CPs in 288 cases of PLG, accounting for 62.5%, followed by inflammatory polyps, adenomatoid hyperplasia and adenomyosis. CPs are local manifestations of abnormal cholesterol metabolism, which is the secretion of cholesterol lipids in the blood and is the wall of the gallbladder. Tissue phagocytosis can occur in any part of the gallbladder, most of which are multiple, appearance yellow lobulated, mulberry-like, soft and easy to fall off, histology shows that polyps are composed of accumulated foam tissue cells, the surface consists of a single columnar epithelium Cover, with connective tissue pedicle, microvascular, branched villi-like bulge, CPs pathological features multiple polyps, 97% of Shinkai 74 cases of CPs diameter <10mm, 50% are multiple, and neoplastic polyps are often Individual, CPs are brittle and thin, easy to separate from the mucosa, without intestinal metaplasia and dysplasia, and do not contain other matrix components, even with inflammation is very mild, so far no cancer has been reported, about CPs Some people think that cholesterol is the cause of CPs. Some people think that cholesterol is the cause of CPs. The cholesterol is deposited in the macrophages of the lamina propria of the gallbladder mucosa, gradually protruding to the mucosal surface, promoting mucosal epithelial hyperplasia, Rokitanski. -Aschoff sinuses) increased and thickened muscle layer to form polyps; but some people think that there is no correlation between the two.
(2) Inflammatory polyps: caused by chronic inflammation, can be single, or multiple, generally 3 ~ 5mm size, thick or not obvious, color similar to the adjacent mucosa or slightly red, single or multiple broad-based Nodules, histology showed that focal glandular epithelial hyperplasia with vascular connective tissue interstitial and obvious inflammatory cell inflammatory polyps, granuloma caused by inflammatory stimulation, obvious inflammation of the gallbladder wall around polyps, no cancerous reports, but no reports From the study of the carcinogenic mechanism of gallbladder carcinoma with gallstone, it is considered that bacterial chronic cholecystitis may be one of the factors, so the inflammatory polyps can not be relaxed.
(3) adenoma-like hyperplasia, adenomyosis: adenoma-like hyperplasia is a gallbladder wall hypertrophic lesion caused by gallbladder epithelium and smooth muscle hyperplasia, divided into 3 types:
1 limited type: the bottom of the gallbladder is thickened by a cone cap.
2 segment type: the locally thickened capsule wall protrudes into the cavity to form a "triangular sign", which is diffusely concentric thickened, the inner wall is rugged, the inner cavity is narrow, sometimes accompanied by stones, and the fat meal test shows gallbladder contraction hyperthyroidism.
3 extensive type: the gallbladder wall is extensive hypertrophy, the inner wall is uneven, and the dilated Luo-A sinus in the wall is a small cystic hypoechoic area. The epithelial hyperplasia is most prominent in the center of the lesion, and the surrounding glands are often cystic. Dilated, and filled with mucus, there is calcium deposition in the dilated gland. Adenomatous hyperplasia and adenomyoma are both non-inflammatory and non-tumor proliferative lesions. The former is a yellow soft sputum, diameter 5mm or so, single or multiple hair, rich in connective tissue containing smooth muscle bundles and goblet cells, epithelial hyperplasia on the surface accompanied by intestinal metaplasia, the latter is local changes in mucosal epithelium, muscle fiber hyperplasia and localized adenomyosis Also known as adenomyomatosis, both of these lesions are cancerous.
2. Tumorous PLG neoplastic lesions are benign with adenoma, and malignant is mainly gallbladder cancer.
(1) adenoma: adenoma is mostly a single pedicled polyp, according to the shape can be divided into papillary or non-papillary, malignant rate of about 30%, papillary adenoma can be subdivided into pedicle and no pedicle Microscopically, it shows a branch or dendritic structure with a thin vascular connective tissue pedicle, connected to the gallbladder wall, with a single layer of cubic or columnar epithelial covering, and a good transition to the surrounding normal gallbladder mucosa. Non-papillary glands Most of the tumors are pedicled. Under the microscope, most of the hyperplasia glands are surrounded by moderate amount of connective tissue interstitial. Occasionally, the gland shows cystic dilatation. This type of adenoma is mainly composed of tubular proliferation of glands. Tube adenoma, sometimes seen in the intestinal epithelial metaplasia of goblet cells or basal granule cells, Koga observed benign PLG lesions 94% <10mm, 69% <60 years; and malignant PLG 88%> 10mm, 75%> 60 years old, However, of the 12,153 cases of cholecystectomy performed by Smok in 10 years, only 81 cases were PLG, with a prevalence of 0.7%, of which only 9.6% were adenomas; in the same period, 225 cases of gallbladder cancer were found, accounting for 1.85%. The incidence of tumors is very low, although there is a possibility of cancer, but it does not constitute a clinical threat.
(2) benign mesenchymal tissue tumors: benign mesenchymal tissue tumors are benign tumors of the gallbladder derived from supporting tissues, including fibroids, leiomyoma, hemangioma, lipoma, myxoma, schwannomas, etc.
(3) adenocarcinoma: adenocarcinoma is divided into nipple type, nodular type and infiltrating type, the first two types are bulging lesions, the diameter is <20mm; and the infiltrating type is not PLG, most of the diameter is >20mm, therefore, the performance Cancers that are PLG tend to belong to the early stage, and most of the papillary adenocarcinomas are confined to the mucosa and muscle layers, and the prognosis is good.
Prevention
Gallbladder polyps prevention
Prohibition of alcohol and alcoholic beverages
Alcohol is mainly decomposed and detoxified in the body by the liver. Therefore, alcohol can directly damage liver function, cause liver and gallbladder dysfunction, cause bile secretion, and disorder the discharge process, thereby stimulating the gallbladder to form new polyps and/or causing the original polyps to grow and become Large, increase the carcinogenesis coefficient of gallbladder polyps.
Dietary principle
Regular diet, eating good breakfast is extremely important for patients with gallbladder polyps. The liver is secreted by the liver in the body, and the secreted bile is stored in the gallbladder. The function of bile is mainly to digest oily food. If you do not eat breakfast, the bile used at night will not be utilized. In the gallbladder, the bile stays in the gallbladder for too long, which can stimulate the gallbladder to form gallbladder polyps or increase the original polyps, so it is best to eat foods containing vegetable oil for breakfast.
Low cholesterol diet
Excessive cholesterol intake can increase the metabolism of liver and gallbladder, clear the burden, and cause excess cholesterol to crystallize, accumulate and precipitate in the gallbladder wall, thus forming polyps. Therefore, patients with gallbladder polyps should lower their cholesterol intake, especially at night. Avoid eating high-cholesterol foods such as eggs (especially egg yolks), fatty meats, seafood, scaleless fish, animal offal and other foods.
Dietary considerations
1, should eat a variety of fresh fruits, vegetables, into low-fat, low-cholesterol foods such as: mushrooms, fungus, celery, bean sprouts, kelp, clams, fish, rabbit, chicken, fresh beans and so on.
2, should eat more dried beans and their products.
3, should choose vegetable oil, not animal oil.
4, eat less pepper, raw garlic and other irritating foods or spicy food
5, should be cooked, steamed, braised, fried, mixed, stewed, stewed cooking methods, no fried, fried, roasted, smoked cooking methods.
6, 10 grams of hawthorn, 10 grams of chrysanthemum, cassia 15 grams, decoction on behalf of tea or drink green tea.
7, when drinking water, usually pinch a little hawthorn, sea buckthorn, ginkgo, gynostemma into the cup to drink.
Complication
Gallbladder polyp complications Complications gallbladder cancer
Polypoid gallbladder cancer accounts for 9% to 12%, BUS characteristics are >10mm, single-shot (82%), mostly in the gallbladder neck (70%), lesions in the middle, low echo, about 50% Gallstones, with the above characteristics, should be used for early radical cholecystectomy. The connective tissue above and below the cystic duct and the fibrous adipose tissue of the gallbladder bed should be removed together.
Symptom
Gallbladder polyps symptoms Common symptoms Appetite decreased biliary colic gallbladder tenderness right upper quadrant pain gallbladder wall fibrosis gallbladder wall thinning gallbladder dyskinesia
Most patients with CPs have no clinical symptoms and the gallbladder function is good. Such patients should be followed up regularly (3 to 6 months). If there are obvious symptoms or PLG increases rapidly, the operation should be considered. If the gallbladder functiones well, Can be used for percutaneous cholecystectomy polyps, such polyps often <10mm (82%), mostly multiple (75%), the appearance of mulberry-like, pedicle as thin, crisp and easy to fall, so it is easy to remove, If the gallbladder is dysfunctional, laparoscopic cholecystectomy (LC) can be performed.
Benign non-cholesterolous PLG accounts for 35%, including adenoma and adenomyoma, inflammatory polyps, adenomatous hyperplasia and rare mesenchymal tumors. Among them, inflammatory polyps have no malignant reports, but are associated with gallbladder inflammation. Most of them have clinical symptoms, and the rest of them have malignant changes. Therefore, once they are found, they should be surgically removed in time to confirm the pathological nature.
Gallbladder polyps can be divided into three periods in clinical practice: active growth period, relative stability period, and absorption dissipation period. In the treatment, it is generally through the process of "active growth period - relative stability period - absorption dissipation period".
Examine
Examination of gallbladder polyps
1.B-ultrasound
The method is flexible, accurate, non-invasive, reproducible, and inexpensive. It is easy for many patients to accept. It can accurately display the size, position, quantity and wall of polyps. The typical performance of B-ultrasound is a little bit of gallbladder wall. Shape, flaky strong or slightly strong echo light group, followed by more silent shadow, visible spherical, mulberry-like, papillary and nodular protrusion, and even can show the pedicle of polyps, Yang Hanliang and other reports B-ultrasonic to PLG The detection rate was 92.7%, the specificity was 94.8%, and the false positive was 5.2%. The accuracy was significantly higher than that of CT. It is considered that BUS can clearly show the location, size, number and local gallbladder wall changes of PLG, which is simple and reliable. diagnosis method.
2. Three-dimensional ultrasound imaging
The gallbladder can have a three-dimensional sense of spatial orientation, good sound permeability, and direct visualization of the gallbladder profile, which can make up for some of the deficiencies of the two-dimensional imaging, not only can observe the size and shape of the gallbladder polyps, but also distinguish the polyps and gallbladder walls. Relationships, especially in the polyp of the posterior wall of the gallbladder, often do not clearly distinguish whether there is a pedicle and the extent and depth of attachment of the pedicle to the gallbladder wall. Three-dimensional reconstruction can observe the continuity of the lesion and the surface of the lesion through the rotation of different sections. Information such as the situation can help to improve the differentiation of gallbladder polyps and gallbladder adenomas or cancers. Wang Liansheng et al reported that 18 cases of gallbladder lesions were examined by three-dimensional ultrasound imaging. The maximum diameter was 5.5cm and the minimum diameter was 0.3cm, of which 5 cases were multiple. In the polyps, 9 cases were single polyps, and 4 cases of gallbladder carcinoma were multiple lesions. Three-dimensional ultrasound imaging was basically consistent with what was seen during surgery.
3. Endoscopic ultrasonography (EUS)
That is, after endoscopic ultrasonography, the ultrasonic micro-probe is placed on the top of the endoscope, the probe is high frequency, the endoscope is inserted into the digestive tract, and the probe is closer to the gallbladder after entering the duodenum ampulla, which can eliminate intestinal gas interference or EUS can divide the gallbladder wall into three layers, the inner layer is a hyperechoic mucosa and the submucosa, the middle layer is a hypoechoic muscle fiber layer, and the outer layer is a hyperechoic subserosal layer and serosal layer, such as For the polypoid lesions, a clear three-layer cyst wall is visible, while in the gallbladder carcinoma, the three-layer structure of the cyst wall has different degrees of infiltration and destruction. Most of the early gallbladder cancer is developed under the cover of stones and polyps, and is lacking in the early stage. Characteristic sonograms, difficult to identify, and EUS examination to observe the relationship between polypoid lesions and gallbladder wall, help differential diagnosis, Zhu Yanling and other retrospective analysis of 103 cases of non-calculus gallbladder disease EUS results and with surface ultrasound and After surgery, the pathological comparison was performed. The correct rate of EUS was 75%, and the surface ultrasound was 41.4%. The coincidence rate of EUS for gallbladder polyps, gallbladder carcinoma and gallbladder adenoma was 100%, and surface ultrasound was 55.6%. Sugiyama Endoscopic ultrasonography (EUS) is considered to be more accurate than BUS, and the images provided are also clearer. In 194 cases of PLG, 136 non-neoplastic lesions judged by EUS were found to have no tumor on average after 2.6 years of follow-up; 13% of the lesions are tumors, and the echo pattern of the EUS inner layer is tiny echonic spot, aggregation of echogenic spot, microcyst and comet tailartifact, such as EUS confirmed that there is no small sound point and sound point aggregation, and there is no microcyst and comet tail sign, it should be suspected as adenoma or cancer, the two can not be identified, unless it has infiltrated into the liver, but if it is pedunculated, then Strongly suggestive of cancer, combined with histological studies, a small sound point indicates a group of tissue cells containing cholesterol foam, while the non-echo area is glandular epithelial hyperplasia, multiple small cysts and comet tails are increased for Luo-A sinus And caused by stones in the gallbladder wall.
Gouma compared CT and enhanced CT in 31 cases of PLG. CT only found 14 cases (45%), while enhanced CT was 100%. Therefore, it is considered that the lesions that can be found without CT enhancement and the pedunculated PLG that enhance CT findings. All tumors should be diagnosed as neoplastic polyps. The diagnosis of pedicled and non-pedicled is very significant. Of the 20 patients with pedicled PLG, 6 were tumors (30%), and 11 of 11 patients without pedicled PLG were tumors (91%). Enhanced CT diagnosis of tumor PLG was 88%, specificity 87%, positive predictive rate 88%, negative predictive rate 87%, total accuracy 87%, concluded that enhanced CT can identify tumor and non-neoplastic PLG, can Reliable screening of neoplastic lesions that should be removed.
4.CT tomographic virtual endoscopy (CTVE)
Since the first report of Vining et al in 1994, many foreign scholars have carried out experiments and clinical application research on this technology. The principle of CTVE imaging is to use the computer software function to post-process the image data obtained by spiral CT volume scanning to reconstruct the cavity. The stereoscopic image of the inner surface of the organ, similar to that seen by endoscopy, has also begun to be applied in clinical practice.
(2) CTVE clinical application value:
The computed tomographic virtual endoscopy of the gallbladde (CTVEGB) can clearly show the normal anatomy of the gallbladder cavity.
2CTVEGB can clearly display the size of gallbladder polyps, the smallest visible 1.5mm × 2.2mm × 2.5mm, can more accurately observe the polyp growth site, morphology, surface, basal and other image changes, and color Doppler ultrasound and surgical pathology is basically the same.
3 can accurately observe the gallbladder single polyps.
(2) The advantages of CTVE in the diagnosis and diagnosis of gallbladder polyps are more prominent, but there are also some shortcomings:
1 The polyp of the flat and wide base is not well displayed, and the rough inner wall of the gallbladder affects the detection of small polyps.
2 scan parameters, workstation post-processing techniques and improper selection of thresholds will cause loss of lesions.
3 is greatly affected by respiratory movement.
4 iodine allergy patients should not do this examination and susceptible to the impact of gallbladder on iodine concentration.
Diagnosis
Diagnosis and identification of gallbladder polyps
diagnosis
PLG often has no clinical symptoms or mild symptoms. The diagnosis mainly depends on imaging. There are many diagnostic methods for gallbladder polypoid lesions, such as oral cholecystography, B-ultrasound, CT, magnetic resonance cholangiopancreatography (MRCP), intracavitary ultrasound ( EUS), etc., but the most important means of diagnosing gallbladder polyps is still B-ultrasound.
Differential diagnosis
1. Color Doppler ultrasound appears in the mass and gallbladder wall high-speed arterial blood flow signal, is an important distinguishing feature of primary gallbladder cancer is different from benign mass and metastatic cancer, such as cholesterol polyps blood flow is linear, < 20cm/s, and the blood flow in gallbladder cancer is mostly dendritic, the flow rate is >20cm/s, the smaller the RI is, the more prone to malignancy, but sometimes it is not sensitive to the small gallbladder cancer mass (<3mm), in addition to There is an important relationship between the skill level of the operator.
2. B-guided cytology of gallbladder puncture, which is helpful for differential diagnosis and can improve the preoperative diagnosis rate. The positive rate of early detection of cancer cells in bile is 64%, and the positive rate in the gallbladder wall. 91%, therefore, it is emphasized that the lesion wall tissue should be selectively punctured under the guidance of B-ultrasound. Some scholars also measured the concentration of carcinoembryonic antigen (CEA) in gallbladder puncture, and the concentration was increased compared with simple gallstone. Highly statistically significant, it also has an auxiliary diagnostic value.
