Incidental Gallbladder Polyps: A Case of Lost Follow-up

Case at a Glance

A 32-year-old female presents with concerns about gallbladder polyps discovered incidentally 3 years prior during evaluation for left-sided abdominal pain, with no subsequent follow-up imaging performed.

Patient's Story

The patient is a 32-year-old female (height 165 cm, weight 77 kg, non-smoker) who initially presented 3 years ago with left-sided abdominal pain. During the workup, abdominal ultrasound revealed bilateral kidney stones and incidental gallbladder polyps. The attending physician noted that the polyps were small and did not require immediate intervention, suggesting routine monitoring. However, the patient's care focused primarily on managing the kidney stones, and the gallbladder polyps were inadvertently not followed up. The patient recently recalled this finding and expressed concern about the lack of surveillance imaging over the 3-year period.

Initial Assessment

Physical examination was unremarkable with no right upper quadrant tenderness or Murphy's sign. The patient reported no symptoms suggestive of biliary disease, including no postprandial pain, nausea, or fatty food intolerance. Her only ongoing symptoms were related to left-sided renal colic from known kidney stones.

The Diagnostic Journey

Initial abdominal ultrasound performed 3 years prior showed multiple small gallbladder polyps of unspecified size, along with bilateral nephrolithiasis. No additional imaging or follow-up was scheduled for the gallbladder findings. The patient's primary care physician acknowledged that surveillance imaging had been inadvertently omitted from her care plan.

Final Diagnosis

Incidental gallbladder polyps with delayed follow-up (size and characteristics to be reassessed with repeat imaging)

Treatment Plan

Repeat abdominal ultrasound scheduled to reassess gallbladder polyps and determine current size, number, and characteristics. Management plan will depend on updated imaging findings, with consideration for routine surveillance if polyps remain small (<6mm) or surgical consultation if significant growth or concerning features are identified.

Outcome and Follow-up

Patient scheduled for follow-up ultrasound. Clinical consultation advised that small gallbladder polyps (≤6mm) typically require minimal intervention and may not necessitate routine surveillance, which provided reassurance regarding the 3-year gap in monitoring.