B超发现胆囊息肉，怎么处置？何时手术?

在肝病科门诊，经常碰到一些患者因常规复查肝脏B超，而发现胆囊息肉，很多患者困惑是否需要手术治疗，那么，胆囊息肉处置流程如何呢？

一位实战病例：

疾病概述

Gallbladder polyps are elevations of the gallbladder wall that project into the lumen. They are commonly detected on ultrasound scans of the abdomen, with a prevalence estimated between 0.3 and 9.5%. They may also be found following analysis of the gallbladder specimen following cholecystectomy.

胆囊息肉是指凸向腔内的胆囊壁隆起性病变。

可通过腹部超声扫描或分析胆囊切除术后的胆囊标本发现，发病率约为 0.3%-9.5%。

Gallbladder polyps can be divided into pseudopolyps and true gallbladder polyps. Pseudopolyps are morecommonthan true polyps. 

In a recent systematic review by Elmasry et al. 70% of suspected gallbladder polyps were pseudopolyps .

Pseudopolyps are most commonly cholesterol pseudopolyps but also include focal adenomyomatosis and inflammatory pseudopolyps. Pseudopolyps do not in themselves have malignant potential. 

True gallbladder polyps can be benign or malignant. Benign polyps are most commonly adenomas while malignant polyps are usually adenocarcinomas. 

There are rare types of benign and malignant true gallbladder polyps,including mesenchymal tumours, lymphoma and metastases.

胆囊息肉分为假性息肉与真性息肉，前者比后者更常见。

最近 Elmasry 等在一篇系统性综述中指出，70%的疑似胆囊息肉为假性息肉。

最常见的假性息肉是胆固醇假性息肉，此外也包括局灶性腺肌症和炎性假性息肉。

假性息肉自身不具有恶变潜能，而真性胆囊息肉则可以是良性或恶性的。

最常见的良性息肉是腺瘤，而恶性息肉通常为腺癌。

其他罕见的良性和恶性的真性胆囊息肉类型包括间质肿瘤、淋巴瘤和转移癌。

临床困难

As gallbladder polyps are common but gallbladder cancer is rare, it is a diagnostic challenge to determine which polyps are likely to be malignant or undergo malignant transformation in order to determine which patients require cholecystectomy.

由于胆囊息肉常见，而胆囊癌少见，对于确定哪些息肉可能是恶性的或正在发生恶性转变进而决定哪些患者需要切除胆囊，正是一个诊断学上的挑战。

 It may be difficult, therefore, for the practising radiologist, clinician or sonographer to know what to recommend when they encounter a gallbladder polyp.

放射科医生、临床医师或超声科医师在临床上遇到胆囊息肉时，推荐何种治疗方法可能存在困难。

息肉定义

Polyp definition

On ultrasound a gallbladder polyp is seen as an elevation of the gallbladder wall that protrudes into the lumen. It should not be mobile or demonstrate posterior acoustic shadowing (which would suggest it is more likely a calculus). It may be sessile or pedunculated.

A clearly infiltrating or large mass should be treated as a gallbladder cancer rather than a polyp.

息肉定义 

超声检查提示的胆囊息肉是指胆囊壁凸向腔内的隆起，不移动，后方不伴有声影(否则结石可能性大);无蒂或有蒂。

明显浸润或大的肿块，应当做胆囊癌而不是息肉来治疗。

If there is clear reverberation or “comet tail” artefact present posterior to the lesion(Fig.2) this should be identified as a pseudopolyp (focal adenomyomatosis or a cholesterol polyp). 

The follow-up guidelines, therefore, do not need to be followed for these patients. 

Of note, not all pseudopolyps will demonstrate these findings.

如果病变后才存在明显回声或“彗星尾”伪像，考虑假性息肉(局限性腺肌症或胆固醇息肉)。根据指南，此类患者无需随访。

值得注意的是，并非所有的假性息肉都具有上述特征。

检查方法

基本检查采用腹部超声，不建议常规使用其他影像学检查。

1.B 超

B超检查方法灵活、准确、无创伤、可重复、价廉、易为众多患者接受。

空腹肝胆 B 超，对胆囊结石及胆囊息肉的诊断率较高，简便易行，能够了解胆囊大小、形态、壁厚、胆囊黏膜情况及胆汁透声情况，能够明确胆囊结石和息肉的大小、位置、形态和活动情况等。

B超典型的表现：胆囊壁有点状、小块状、片状的强或稍强回声光团，其后多无声影，可见到球状、桑葚状、乳头状及结节状突出，甚至可显示出息肉的蒂。

在某些具备合适的专门技术和资源的医学中心，替代性影像学检查手段［如内镜超声(EUS)］有助于对疑难病例做出决策(低质量证据，100%认同度) 替代性影像学检查已经显示出良好的前景。

一些小样本研究证实，EUS 检查比常规超声更准确。

对于胆囊息肉的患者，超声造影检查有助于鉴别息肉性质。

2.MRCP

MRCP对于胆囊息肉的诊断率较低，对于单纯的胆囊息肉患者，无需行 MRCP 检查。

3.ECT

Emission Computed Tomography (ECT,发射单光子计算机断层扫描仪)肝胆显像,是一种利用放射性核素的检查方法。因胆囊息肉对胆囊功能几乎无影响，故胆囊息肉患者术前无需行ECT检查。

处置流程图

是否手术？

Thus, if cholecystectomy is performed for a gallbladder polyp 10 mm or larger then it is not only more likely that the lesion is malignant but if it is not malignant then it is more likely to be an adenoma and thus have malignant potential.

Some authors, such as Bhatt et al., have suggested higher threshold values for cholecystectomy. 

The group concluded, however, that more evidence is available for the 10mm threshold.

注：仅供参考，请以专科的意见为主！

参考文献：

1.LU H，LIU QD． An excerpt of Joint guidelines between the European Society of Gastrointestinal and Abdominal Ｒadiology (ESGAＲ)，European Association for Endoscopic Surgery and other Interventional Techniques (EAES)，International Society of Digestive Surgery － European Federation (EFISDS) and European Society of Gastrointestinal Endoscopy (ESGE): management and follow-up of gallbladder polyps(2017)［J］． J Clin Hepatol，2017，33(6): 1051 －1055． (in Chinese)

卢昊，刘全达． 《2017 年欧洲多学会联合指南:胆囊息肉管理和随访》摘译［J］． 临床肝胆病杂志，2017，33(6): 1051 －1055.

2.中国医师协会内镜医师分会内镜微创保胆专业委员会.内镜微创保胆手术治疗胆囊良性疾病专家共识（2018 版）.中国内镜杂志.2018年9月第24卷第9期

3..刘厚宝 王越琦.胆囊息肉及胆囊结石与胆囊癌的争议与共识.中国实用外科杂志 2014年1月第34卷第1期