Transabdominal ultrasound and endoscopic ultrasound for diagnosis of gallbladder polyps

The Many Faces of Primary Sclerosing Cholangitis: Controversy Abounds

Primary sclerosing cholangitis (PSC) is notoriously challenging to manage given its heterogeneity with regard to diagnosis, management, and progression. The lack of disease-modifying therapy and variable rate of onset of cirrhosis, portal hypertension-related decompensating events, jaundice, pruritus, biliary complications, and need for liver transplantation is deeply unsettling to clinicians and patients alike. Recent updated practice guidance by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver endeavored to highlight some of these challenges. However, these references only briefly address clinical dilemmas that providers face on a daily basis. This review aims to further discuss these controversial topics, including providing insight into the utility of ursodeoxycolic acid, the significance of alkaline phosphatase normalization, when to consider PSC variants and mimickers, and the implications of continuous hepatobiliary malignancy screening. In particular, there has been a growing body of literature raising concern about repeat exposure to gadolinium-containing contrast. Patients with PSC are potentially at risk for large lifetime exposure to gadolinium related to frequent magnetic resonance imaging scans and whether this carries any negative long-term adverse effects remains unknown.

A New Risk Scoring System to Predict Malignancy in Gallbladder Polyps: a Single-Center Study

OBJECTIVE

Ultrasonography (US) is the most commonly used radiological method in the diagnosis of gallbladder polyps (GBPs). Patients diagnosed with GBPs on US are operated on with risk factors that do not have a high level of evidence. Our aim in this study is to determine the sensitivity of US in diagnosis GBPs, to define risk factors for neoplastic (NP) polyps, and to develop the risk scoring system.

MATERIALS AND METHODS

Between July 2011 and July 2021, 173 patients who were found to have GBPs in the pathology specimens after cholecystectomy were included in the study. Patients were divided into two groups: nonneoplastic and NP groups.

RESULTS

GBPs in patients who underwent abdominal US for any reason was 4.5%. The sensitivity of US in the diagnosis of GBPs was 56.6%. Comparison between groups, age ≥50, presence of symptoms, polyp size >12.5mm, single polyp, concomitant gallstones, and gallbladder wall thickness ≥4mm were statistically in the NP group. A risk scoring system was developed using these values. If the risk score was <4, 0.6% of GBPs was NP polyps. If the risk score was ≥4, 63.2% of GBPs were NP polyps.

CONCLUSION

Our risk scoring system can prevent unnecessary choelcystectomy. Because the incidence of NP polyps in low-risk patients (risk score <4) is extremely rare.

Gallbladder Polyp and Cancer Evaluation After Cholecystectomy: A Retrospective Observational Study

Introduction

Our aim in this study is to examine the clinical features of gallbladder polyps (GBPs) detected by preoperative ultrasonography (USG) or after cholecystectomy, especially benign and malignancy.

Methods

One thousand seven hundred patients between the ages of 18-80 who were operated on for cholecystectomy between January 1, 2015, and January 1, 2020, in Ankara Batıkent Medicalpark hospital were evaluated in this study. Of these patients, 149 patients who were operated on due to polyp detected in USG, who were accompanied by polyp while being operated on for another reason, or who had a benign or malignant polypoid structure in postoperative pathology were examined. Mann-Whitney U test was used for continuous variables and the chi-square test was used for categorical variables.

Results

The mean age for patients with polyps was 44.6 years (range: 21-78). When the patient distribution was evaluated according to gender, although women were more, they were proportionally close to each other (female 77 (51.7%), male 72 (48.3%)). When the polyps were examined in pathology, 20 (13.4%) patients did not have polyps. Given the other patients, hyperplastic polyps were detected in 15 (10.1%), cholesterol polyps in 104 (69.8%), and adenocarcinomas in five (3.4%) of them. Of the patients with adenocarcinoma, two had T2 and three had T1 tumors. Two of the patients with gallbladder cancer had sessile polyps below 5 mm. Of the malignant cases, four were female and one was male. The median age in malignant cases was 55 years. All malignant cases had single polyps.

Conclusion

In conclusion, in our study, it was observed that most postoperative GBPs were benign - malignancy should come to mind at an advanced age - and was compatible with current malignant polyp risk factors. Contrary to the literature, female gender dominance was present in our malignant cases.

[Imaging of intrahepatic cholangiocarcinoma : Reliable diagnosis according to the new S3 guideline]

The S3 guideline on hepatocellular carcinoma has been expanded to include malignant biliary carcinoma (synonym cholangiocarcinoma [CCA]). Magnetic resonance imaging (MRI) with additional magnetic resonance cholangiopancreatography (MRCP) is the imaging modality of choice to evaluate local findings. Use of gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid (Gd-EOB-DTPA)-based contrast agent increases its diagnostic value. Histologic confirmation is always required when diagnosing intrahepatic CCA (iCCA) because using imaging alone there is a risk of confusion with HCC subtypes.

Grayscale ultrasonography findings for characterization of gallbladder wall thickening in non-acute setting: a systematic review and meta-analysis

BACKGROUND

The accurate characterization of gallbladder wall thickening (GWT) into benign or malignant on ultrasound (US) is a significant challenge.

METHODS

We searched the MEDLINE and EMBASE databases for studies reporting two-dimensional grayscale US in benign and malignant GWT. The pooled prevalence was calculated using a generalized linear mixed method with a random-effects model. The pooled sensitivity and specificity were calculated using a bivariate random-effects model.

RESULTS

Of the 7309 studies screened by titles, 73 studies with 18,008 patients were included. The most common findings in xanthogranulomatous cholecystitis (XGC) were lack of wall disruption and intramural hypoechoic nodules while adenomyomatosis (ADM) was frequently associated with intramural cysts and intramural echogenic foci. Echogenic foci, lack of gallbladder wall disruption, and hypoechoic nodules had a sensitivity of 89%, 77%, and 66% and specificity of 86%, 51%, and 80%, respectively for the diagnosis of benign GWT. Focal thickening and indistinct liver interface had a sensitivity of 75% and 55% and specificity of 64% and 69%, respectively for the diagnosis of malignant GWT.

CONCLUSION

intramural features (echogenic foci, hypoechoic nodules), gallbladder wall disruption, and liver interface are useful US features for the characterization of GWT.

Segnet Network Algorithm-Based Ultrasound Images in the Diagnosis of Gallbladder Stones Complicated with Gallbladder Carcinoma and the Relationship between P16 Expression with Gallbladder Carcinoma

The study focused on how to improve the diagnostic coincidence rate of patients with gallbladder stones and gallbladder cancer based on an optimized Segnet network algorithm and the relationship of gallbladder cancer with multiple tumor suppressor 1 (P16). 300 patients diagnosed with gallbladder cancer in the hospital were selected as the research subjects. The pyramid pooling operation was incorporated into the original Segnet network algorithm, and its performance was evaluated, factoring into the intersection of union (IoU), algorithm precision (Pre), and recall rate (Recall). After 8 hours of fasting, conventional ultrasound and contrast-enhanced ultrasound examinations were performed, and the images were evaluated by three experienced ultrasound diagnosticians. The positive signal of P16 immunohistochemical staining was brownish yellow, which was generally concentrated in the nucleus, and a small part was located in the cytoplasm. In each slice, ten visual fields were selected. Then, they were observed under a high-power mirror, and the number was counted. It was found that the optimized Segnet network algorithm increased the IoU by 7.3%, the precision by 8.2%, and the recall rate by 11.1%. The diagnostic coincidence rates of conventional ultrasound and contrast-enhanced ultrasound examinations for gallbladder cancer were 78.13% (25/32) and 87.5% (25/32), respectively. The positive expression rate of P16 in gallbladder adenocarcinoma (47.06%) was significantly lower than that of acute cholecystitis with gallbladder stones (84.38%) and gallbladder polyps (67.16%) (P < 0.05). The positive expression rate of P16 in patients with stage III and stage IV (33.33% and 40%) was significantly lower than that in patients with stages I and II (87.5% and 80%) (P < 0.05). The positive expression rate of P16 in high differentiation (86.67%) was significantly higher than that of moderate differentiation (40%) and poor differentiation (28.57%) (P < 0.05). In short, contrast-enhanced ultrasound can effectively improve the diagnostic coincidence rate of gallbladder cancer, and the expression of P16 in gallbladder cancer is closely related to tumor staging and differentiation.

Management and follow-up of gallbladder polyps: updated joint guidelines between the ESGAR, EAES, EFISDS and ESGE

Abstract

Main recommendations

Primary investigation of polypoid lesions of the gallbladder should be with abdominal ultrasound. Routine use of other imaging modalities is not recommended presently, but further research is needed. In centres with appropriate expertise and resources, alternative imaging modalities (such as contrast-enhanced and endoscopic ultrasound) may be useful to aid decision-making in difficult cases. Strong recommendation, low–moderate quality evidence.

Cholecystectomy is recommended in patients with polypoid lesions of the gallbladder measuring 10 mm or more, providing the patient is fit for, and accepts, surgery. Multidisciplinary discussion may be employed to assess perceived individual risk of malignancy. Strong recommendation, low-quality evidence.

Cholecystectomy is suggested for patients with a polypoid lesion and symptoms potentially attributable to the gallbladder if no alternative cause for the patient’s symptoms is demonstrated and the patient is fit for, and accepts, surgery. The patient should be counselled regarding the benefit of cholecystectomy versus the risk of persistent symptoms. Strong recommendation, low-quality evidence.

If the patient has a 6–9 mm polypoid lesion of the gallbladder and one or more risk factors for malignancy, cholecystectomy is recommended if the patient is fit for, and accepts, surgery. These risk factors are as follows: age more than 60 years, history of primary sclerosing cholangitis (PSC), Asian ethnicity, sessile polypoid lesion (including focal gallbladder wall thickening > 4 mm). Strong recommendation, low–moderate quality evidence.

If the patient has either no risk factors for malignancy and a gallbladder polypoid lesion of 6–9 mm, or risk factors for malignancy and a gallbladder polypoid lesion 5 mm or less, follow-up ultrasound of the gallbladder is recommended at 6 months, 1 year and 2 years. Follow-up should be discontinued after 2 years in the absence of growth. Moderate strength recommendation, moderate-quality evidence.

If the patient has no risk factors for malignancy, and a gallbladder polypoid lesion of 5 mm or less, follow-up is not required. Strong recommendation, moderate-quality evidence.

If during follow-up the gallbladder polypoid lesion grows to 10 mm, then cholecystectomy is advised. If the polypoid lesion grows by 2 mm or more within the 2-year follow-up period, then the current size of the polypoid lesion should be considered along with patient risk factors. Multidisciplinary discussion may be employed to decide whether continuation of monitoring, or cholecystectomy, is necessary. Moderate strength recommendation, moderate-quality evidence.

If during follow-up the gallbladder polypoid lesion disappears, then monitoring can be discontinued. Strong recommendation, moderate-quality evidence.

Source and scope

These guidelines are an update of the 2017 recommendations developed 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). A targeted literature search was performed to discover recent evidence concerning the management and follow-up of gallbladder polyps. The changes within these updated guidelines were formulated after consideration of the latest evidence by a group of international experts. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence.

Key Point

• These recommendations update the 2017 European guidelines regarding the management and follow-up of gallbladder polyps.

The effect of shortening the preoperative fasting period on patient comfort and gastrointestinal function after elective laparoscopic surgery

OBJECTIVE

To explore the influence of shortening preoperative fasting on the comfort and gastrointestinal function of patients undergoing elective laparoscopic surgery.

METHODS

a total of 179 patients undergoing elective laparoscopic cholecystectomies (LC) in our hospital from March, 2019 to August, 2020 were recruited as the study cohort and placed into the research group (n=97) or the control group (n=82) according to different fasting periods assigned to each patient. In the control group, the patients were subjected to 12-h fasting and 6-h water deprivation before their surgeries, and the patients in the research group were subjected to 6-h fasting and 2-h water deprivation. The preoperative hunger and thirst, comfort, anxiety, and intraoperative aspiration, as well as the postoperative hospital stay durations, the blood glucose levels, the nausea and vomiting, the pain levels, and the times to the recovery of gastrointestinal function were compared between the two groups.

RESULTS

The research group had shorter hospital stay durations and decreased blood glucose levels. No intraoperative aspiration occurred in either group, and the incidence of postoperative nausea and vomiting in the research group was lower than it was in control group. The patients in the research group were less hungry and thirsty and were more comfortable in the preoperative period, and their preoperative self-rating anxiety scale (SAS) and postoperative visual analog scale (VAS) scores were lower than the corresponding scores in the control group. The times to first oral feeding, ambulation, anal flatus, defecation, and bowel sounds in the research group were earlier than they were in the control group.

CONCLUSION

Shortening preoperative fasting improves the comfort levels of patients undergoing elective LC, alleviates thirst and hunger, promotes the recovery of gastrointestinal function, and relieves preoperative anxiety, postoperative pain, and adverse reactions.

The Role of Endoscopic Ultrasound in the Diagnosis of Gallbladder Lesions

Gallbladder (GB) diseases represent various lesions including gallstones, cholesterol polyps, adenomyomatosis, and GB carcinoma. This review aims to summarize the role of endoscopic ultrasound (EUS) in the diagnosis of GB lesions. EUS provides high-resolution images that can improve the diagnosis of GB polypoid lesions, GB wall thickness, and GB carcinoma staging. Contrast-enhancing agents may be useful for the differential diagnosis of GB lesions, but the evidence of their effectiveness is still limited. Thus, further studies are required in this area to establish its usefulness. EUS combined with fine-needle aspiration has played an increasing role in providing a histological diagnosis of GB tumors in addition to GB wall thickness.

The Role of EUS and EUS-FNA in Differentiating Benign and Malignant Gallbladder Lesions

Endoscopic ultrasonography (EUS) has greater spatial resolution than other diagnostic imaging modalities. In addition, if gallbladder lesions are found and gallbladder cancer is suspected, EUS is an indispensable modality, enabling detailed tests for invasion depth evaluation using the Doppler mode and ultrasound agents. Furthermore, for gallbladder lesions, EUS fine-needle aspiration (EUS-FNA) can be used to differentiate benign and malignant forms of conditions, such as xanthogranulomatous cholecystitis, and collect evidence before chemotherapy. EUS-FNA is also useful for highly precise and specific diagnoses. However, the prevention of bile leakage, an accidental symptom, is highly important. Advancements in next-generation sequencing (NGS) technologies facilitate the application of multiple parallel sequencing to EUS-FNA samples. Several biomarkers are expected to stratify treatment for gallbladder cancer; however, NGS can unveil potential predictive genomic biomarkers for the treatment response. It is believed that NGS may be feasible with samples obtained using EUS-FNA, further increasing the demand for EUS-FNA.

The diagnostic value of high-frequency ultrasound combined with color Doppler ultrasound versus surgical pathology in gallbladder polyps

OBJECTIVE

This study aimed to analyze the value of high-frequency ultrasound combined with color Doppler ultrasound in the diagnosis of gallbladder polyps.

METHODS

A retrospective analysis was performed on 108 patients with gallbladder polyps, all of whom were examined by high-frequency ultrasound and color Doppler ultrasound with surgical or pathological findings as the gold standard.

RESULTS

Taking surgical pathology findings as the gold standard, the diagnostic accuracy, sensitivity and specificity of high-frequency ultrasound for gallbladder polyps were 63.89%, 63.27%, and 70.00%, respectively. The diagnostic accuracy, sensitivity and specificity of color Doppler ultrasound were 74.07%, 73.47%, and 80.00%, respectively. The diagnostic accuracy, sensitivity and specificity of high-frequency ultrasound combined with color Doppler ultrasound were 91.67%, 90.82%, and 100.00%, respectively. The proportion of mulberry-like or papillary projections was 56.18% in 89 benign lesions diagnosed by high-frequency ultrasound combined with color Doppler ultrasound, the proportion of hyperechoic lesion was 47.19%, and the proportion of single lesion was 59.55%. The incidence rate of blood flow signal was 26.97% in 89 benign lesions, including 10 cases of punctiform blood flow signal, 9 cases of band-like blood flow signal and 5 cases of multiple stones in the lumen of the gallbladder.

CONCLUSION

High-frequency ultrasound combined with color Doppler ultrasound has high accuracy in the diagnosis of gallbladder polyps, and can yield better diagnostic results than either method, which can be used as an optional method for the diagnosis of gallbladder polyps.

Current update on gallbladder carcinoma

Gallbladder (GB) carcinoma is a relatively rare malignancy and is associated with poor prognosis. Numerous risk factors have been associated with the development of GB carcinoma. GB carcinomas may present as mass lesions replacing the GB, focal or diffuse thickening of the GB wall, and intraluminal mass in the GB. Various benign conditions can mimic GB carcinoma. This article reviews the epidemiology, pathology, clinical findings, imaging features, and management of GB carcinomas.

Detectability on Plain CT is an Effective Discriminator between Carcinoma and Benign Disorder for a Polyp >10 mm in the Gallbladder

An appropriate diagnosis is required to avoid unnecessary surgery for gallbladder cholesterol polyps (GChPs) and to appropriately treat pedunculated gallbladder carcinomas (GCs). Generally, polyps >10 mm are regarded as surgical candidates. We retrospectively evaluated plain and contrast-enhanced (CE) computed tomography (CT) findings and histopathological features of 11 early GCs and 10 GChPs sized 10–30 mm to differentiate between GC and GChP >10 mm and determine their histopathological background. Patient characteristics, including polyp size, did not significantly differ between groups. All GCs and GChPs were detected on CE-CT; GCs were detected more often than GChPs on plain CT (73% vs. 9%; p < 0.01). Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy for GCs were 73%, 90%, 89%, 75%, and 81%, respectively. On multivariate analysis, lesion detectability on plain CT was independently associated with GCs (odds ratio, 27.1; p = 0.044). Histopathologically, GChPs consisted of adipose tissue. Although larger vessel areas in GCs than in GChPs was not significant (52,737 μm² vs. 31,906 μm²; p = 0.51), cell densities were significantly greater in GCs (0.015/μm² vs. 0.0080/μm²; p < 0.01). Among GPs larger than 10 mm, plain CT could contribute to differentiating GCs from GChPs.

Synchronous gallbladder metastasis of renal cell carcinoma presenting as a gallbladder polyp: A case report

RATIONALE

Gallbladder polyps are common in the general population, but gallbladder metastasis of renal cell carcinoma (RCC) is very rare. In a patient with RCC diagnosed with a small gallbladder polyp that does not meet the traditional size criteria, the surgeon faces a dilemma of whether cholecystectomy should be performed given the possibility of metastasis.

PATIENT CONCERNS

A 55-year-old man who had received a left nephrectomy for RCC presented with a gallbladder polyp that was noted at the time of the nephrectomy. Imaging showed the maximum diameter of the polyp had increased from 5 mm to 24 mm in the 40 months after the initial diagnosis.

DIAGNOSIS

Pathological and immunohistology findings confirmed the gallbladder polyp as a metastasis of clear-cell RCC.

INTERVENTIONS

: We performed a laparoscopic cholecystectomy.

OUTCOMES

Even though the synchronous solitary gallbladder metastasis was left untreated and a cholecystectomy was not performed over the 40 months, no metastasis occurred in other sites. The patient is free from disease 10 months after the cholecystectomy.

LESSONS

Solitary gallbladder metastasis of RCC may have more favorable outcomes than typical metastases. Although gallbladder metastasis of RCC occur rarely, it can occur, and any changes in gallbladder polyps in RCC patients should be managed under a strong suspicion of metastasis.

MicroRNA-182 promotes epithelial-mesenchymal transition by targeting FOXN3 in gallbladder cancer

Increasing evidence has suggested an association between the expression profiles of microRNAs (miRs) and gallbladder cancer (GBC). Recently, miR-182 has been demonstrated to exert tumor-promoting effects. However, the biological activity and molecular mechanisms of miR-182 in GBC remain unclear. The results of the present study demonstrated that miR-182 expression was significantly upregulated in GBC tissues and cell lines (GBC-SD and SGC-996). In addition, miR-182-knockdown attenuated epithelial-mesenchymal transition (EMT) in GBC cells, as indicated by decreased cell migratory and invasive abilities, decreased vimentin expression, and increased E-cadherin expression. The activities of β-catenin and its downstream factors, Cyclin D1 and c-Myc, were also demonstrated to decrease following miR-182-knockdown. Forkhead box N3 (FOXN3) was identified as the direct target of miR-182. Overexpression of FOXN3 ameliorated EMT and the β-catenin pathway. Taken together, the results of the present study suggested that miR-182 promotes EMT in GBC cells by targeting FOXN3, which suppresses the Wnt/β-catenin pathway.

[Gallbladder polyps: modern approaches to diagnostics and treatment]

Gallbladder polyps are an elevation of the mucous membrane that protrudes into the lumen of the gallbladder cavity. Their prevalence in the general population varies from 0.3 to 13.8%. According to the modern classification, polyps of the gallbladder are divided into benign non-tumor, benign tumor and malignant tumor polyps. A review of modern literature presents cohort and randomized controlled trials, including those summarized in meta-analyzes and systematic reviews, suggesting that the dominant form of polypoid formations of the gallbladder are cholesterol pseudo-polyps with no malignant potential associated with impaired cholesterol metabolism, often combined with gallbladder cholesterosis, metabolic syndrome and cardiovascular morbidity. Evidence is building up on the effectiveness of ursodeoxycholic acid for controlling components of the metabolic syndrome and cardiovascular risks. Ursodeoxycholic acid preparations may become promising for the management of cholesterol polyps.

Overtreatment of Nonneoplastic Gallbladder Polyps due to Inadequate Routine Ultrasound Assessment

BACKGROUND

The primary aim was to assess the diagnostic accuracy of routine ultrasound assessment for gallbladder polyps. The secondary aim was to identify the characteristics that differentiate neoplastic polyps from nonneoplastic polyps.

METHODS

A total of 156 patients with histopathologically proven gallbladder polyps in 4 Dutch hospitals between 2003 and 2013 were included. Sensitivity and specificity of ultrasound for polyp size, number of polyps, and polyp type were assessed using histopathological findings as a reference standard. In addition, diagnostic accuracy of sonographic size ≥1 cm for neoplasia was assessed. Subgroup analysis for patients with polyps as primary indication for cholecystectomy was performed. The sonographic polyp characteristics on preoperative routine ultrasound were described.

RESULTS

Fifty-six percent of gallbladder polyps were preoperatively identified on ultrasound, of which 31% were neoplastic. Sensitivity and specificity of ultrasound to estimate polyp size were 93 and 43% (subgroup; 92 and 33%). Sensitivity and specificity of sonographic polyp size ≥1 cm for neoplasia were 86 and 32% (subgroup; 94 and 26%). No specific sonographic characteristics for neoplastic polyps could be established due to lack of reporting.

CONCLUSION

Routine ultrasound assessment of polyps is associated with overestimation of polyp size and low specificity of sonographic size ≥1 cm for neoplasia, which contributes to surgical overtreatment of nonneoplastic polyps.

[Surgical treatment of gallbladder polyps]

OBJECTIVE

To study the incidence of gallbladder polyps and the possibilities of modern methods of diagnosis and surgical treatment of this disease.

MATERIAL AND METHODS

There were 42 laparoscopic cholecystectomies in patients with diagnosed gallbladder polyps. The polyps were diagnosed preoperatively. Intraoperative diagnosis during surgery for gallstone disease was observed in 3 cases. A comparative analysis of preoperative examination did not reveal any advantages of certain diagnostic approach.

RESULTS

Hyperplastic polyp was the most common type (n=20, 47.6%), adenomatous polyps occurred in 19 (45.3%) cases, cholesteric polyps - in 3 (7.1%) patients. All patients had signs of chronic inflammation of the gallbladder wall with its infiltration by lymphocytes and histiocytes.

CONCLUSION

Further studies with clear criteria for the diagnosis of gallbladder polyps including ones for determining true polyps, precancerous and malignant polyps are required.

Knockdown of LINC01694 inhibits growth of gallbladder cancer cells via miR-340-5p/Sox4

PURPOSE

The indispensable role of long non-coding RNAs (lncRNAs) in tumorigenesis has been increasingly reported. In the present study, LINC01694 was found to regulate the proliferation, invasion, as well as apoptosis in gallbladder cancer (GBC) cells through sponging miR-340-5p.

METHODS

LINC01694 level in GBC cells was quantified by quantitative real-time polymerase chain reaction (qRT-PCR). The proliferation, invasion, and apoptosis were determined by Cell Counting Kit-8 (CCK-8), Transwell, and flow cytometry, respectively. The expression of Sry-related high-mobility group box 4 (Sox4) was detected by Western blot (WB). The interaction between LINC01694 and miR-340-5p was measured by dual-luciferase reporter (DLR) assay, RNA immunoprecipitation (RIP) test, and RNA pull-down. Tumor formation was examined by in vivo experiment.

RESULTS

qRT-PCR illustrated that cancerous tissues had higher LINC01694 than normal tissues. Survival analysis demonstrated that the prognosis of patients with high LINC01694 was significantly poorer than those with low LINC01694. Down-regulation of LINC01694 slowed down the proliferation and invasion in GBC cells and accelerated the apoptosis. DLR assay indicated that LINC01694 elevated Sox4 expression by regulating miR-340-5p. LINC01694 functioned as miR-340-5p sponge to inhibit Sox4 expression.

CONCLUSION

LINC01694 level is elevated in GBC by regulating miR-340-5p/Sox4 axis, which indicates the poor prognosis of the patients.

Optimization of diagnostic ultrasonography of the gallbladder based on own experience and literature

Although transabdominal imaging of the gallbladder has become a gold standard, new light should be shed on some aspects, which will prove useful in everyday practice. Therefore, based on our own experience and the available literature, we would like to draw attention to those elements of gallbladder ultrasound imaging which may increase its diagnostic efficacy. The paper draws attention to the difficulty in assessing certain anatomical structures, such as the inferior wall, the bottom and the region of the neck of the gallbladder, and offers ways to improve their imaging. We also emphasized the negative effects of duodenal and transverse colon (along with their contents) adhesion to the bottom of the gallbladder on the correct diagnosis. Due to the importance of size in the management strategy for detected gallbladder polyps, we suggest their measurement on an image enlarged with the zoom function. This technique also allows for an accurate assessment of the shape and echostructure of these lesions. An enlarged image of a polyp makes it possible to trace its behavior in time. We also remind that the hepatic wall of the gallbladder is the only site allowing for a reliable wall thickness measurement. We also pointed to the importance of changing patient's position when assessing the mobility and the nature of lesions. Altering patient's position during examination may help detect anomalies in the form of a floating gallbladder, which may promote its torsion. Finally, pathologies whose diagnosis may be facilitated by color-coded blood flow imaging are also presented. The issues discussed in this paper are only a fraction of problems faced by an ultrasound operator in the field of gallbladder diagnostic imaging. However, the proposed ultrasound approaches should help solve some of these problems in everyday practice.

Although transabdominal imaging of the gallbladder has become a gold standard, new light should be shed on some aspects, which will prove useful in everyday practice. Therefore, based on our own experience and the available literature, we would like to draw attention to those elements of gallbladder ultrasound imaging which may increase its diagnostic efficacy. The paper draws attention to the difficulty in assessing certain anatomical structures, such as the inferior wall, the bottom and the region of the neck of the gallbladder, and offers ways to improve their imaging. We also emphasized the negative effects of duodenal and transverse colon (along with their contents) adhesion to the bottom of the gallbladder on the correct diagnosis. Due to the importance of size in the management strategy for detected gallbladder polyps, we suggest their measurement on an image enlarged with the zoom function. This technique also allows for an accurate assessment of the shape and echostructure of these lesions. An enlarged image of a polyp makes it possible to trace its behavior in time. We also remind that the hepatic wall of the gallbladder is the only site allowing for a reliable wall thickness measurement. We also pointed to the importance of changing patient’s position when assessing the mobility and the nature of lesions. Altering patient’s position during examination may help detect anomalies in the form of a floating gallbladder, which may promote its torsion. Finally, pathologies whose diagnosis may be facilitated by color-coded blood flow imaging are also presented. The issues discussed in this paper are only a fraction of problems faced by an ultrasound operator in the field of gallbladder diagnostic imaging. However, the proposed ultrasound approaches should help solve some of these problems in everyday practice.

The accuracy of ultrasonography for diagnosis of gallbladder polyps

INTRODUCTION

Gallbladder polyps (GBPs) are gallbladder lesions which can progress to gallbladder malignancy. The incidence has been estimated as high as 12.1% of all cholecystectomy patients. Gallbladder malignancy typically presents late, and therefore carries a poor prognosis. By identifying potential GBPs early, it would be possible to treat polyps before they undergo malignant change. The current gold standard for GBP identification is with histological examination which is performed after cholecystectomy. This study sought to assess whether radiological imaging could reliably identify GBPs and therefore guide management.

METHODS

1000 consecutive patients already undergoing cholecystectomy were sampled from two UK hospitals. Patients who underwent ultrasonography and had histological analysis of their gallbladders were selected. Overall 905 patients were included in the study.

RESULTS

There were 12 histologically confirmed GBPs in the cohort (1.33%). US correctly detected 1 GBP, with a sensitivity of 8.3% (95% CI 0.2-38.5%) and specificity of 96.0% (95% CI 94.5-97.2%). The overall accuracy was 94.8 (95% CI 93.2-96.2%).

CONCLUSION

These data show that US is an ineffective tool for GBP identification. The lack of prior operator exposure, imprecise nature of US and possible obstruction of images from underlying gallstone disease delivered a high rate of false positives.

IMPLICATIONS FOR PRACTICE

Surgical or oncological decisions regarding GBPs should not be based upon US findings alone as this would lead to unnecessary interventions. MRI should be investigated as an alternative imaging modality for GBP identification, as its differentiation of soft tissues could guide surgical management.

Transabdominal ultrasound and endoscopic ultrasound for diagnosis of gallbladder polyps

BACKGROUND

Approximately 0.6% to 4% of cholecystectomies are performed because of gallbladder polyps. The decision to perform cholecystectomy is based on presence of gallbladder polyp(s) on transabdominal ultrasound (TAUS) or endoscopic ultrasound (EUS), or both. These polyps are currently considered for surgery if they grow more than 1 cm. However, non-neoplastic polyps (pseudo polyps) do not need surgery, even when they are larger than 1 cm. True polyps are neoplastic, either benign (adenomas) or (pre)malignant (dysplastic polyps/carcinomas). True polyps need surgery, especially if they are premalignant or malignant. There has been no systematic review and meta-analysis on the accuracy of TAUS and EUS in the diagnosis of gallbladder polyps, true gallbladder polyps, and (pre)malignant polyps.

OBJECTIVES

To summarise and compare the accuracy of transabdominal ultrasound (TAUS) and endoscopic ultrasound (EUS) for the detection of gallbladder polyps, for differentiating between true and pseudo gallbladder polyps, and for differentiating between dysplastic polyps/carcinomas and adenomas/pseudo polyps of the gallbladder in adults.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, and trial registrations (last date of search 09 July 2018). We had no restrictions regarding language, publication status, or prospective or retrospective nature of the studies.

SELECTION CRITERIA

Studies reporting on the diagnostic accuracy data (true positive, false positive, false negative and true negative) of the index test (TAUS or EUS or both) for detection of gallbladder polyps, differentiation between true and pseudo polyps, or differentiation between dysplastic polyps/carcinomas and adenomas/pseudo polyps. We only accepted histopathology after cholecystectomy as the reference standard, except for studies on diagnosis of gallbladder polyp. For the latter studies, we also accepted repeated imaging up to six months by TAUS or EUS as the reference standard.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts, selected studies for inclusion, and collected data from each study. The quality of the studies was evaluated using the QUADAS-2 tool. The bivariate random-effects model was used to obtain summary estimates of sensitivity and specificity, to compare diagnostic performance of the index tests, and to assess heterogeneity.

MAIN RESULTS

A total of 16 studies were included. All studies reported on TAUS and EUS as separate tests and not as a combination of tests. All studies were at high or unclear risk of bias, ten studies had high applicability concerns in participant selection (because of inappropriate participant exclusions) or reference standards (because of lack of follow-up for non-operated polyps), and three studies had unclear applicability concerns in participant selection (because of high prevalence of gallbladder polyps) or index tests (because of lack of details on ultrasound equipment and performance). A meta-analysis directly comparing results of TAUS and EUS in the same population could not be performed because only limited studies executed both tests in the same participants. Therefore, the results below were obtained only from indirect test comparisons. There was significant heterogeneity amongst all comparisons (target conditions) on TAUS and amongst studies on EUS for differentiating true and pseudo polyps.Detection of gallbladder polyps: Six studies (16,260 participants) used TAUS. We found no studies on EUS. The summary sensitivity and specificity of TAUS for the detection of gallbladder polyps was 0.84 (95% CI 0.59 to 0.95) and 0.96 (95% CI 0.92 to 0.98), respectively. In a cohort of 1000 people, with a 6.4% prevalence of gallbladder polyps, this would result in 37 overdiagnosed and seven missed gallbladder polyps.Differentiation between true polyp and pseudo gallbladder polyp: Six studies (1078 participants) used TAUS; the summary sensitivity was 0.68 (95% CI 0.44 to 0.85) and the summary specificity was 0.79 (95% CI 0.57 to 0.91). Three studies (209 participants) used EUS; the summary sensitivity was 0.85 (95% CI 0.46 to 0.97) and the summary specificity was 0.90 (95% CI 0.78 to 0.96). In a cohort of 1000 participants with gallbladder polyps, with 10% having true polyps, this would result in 189 overdiagnosed and 32 missed true polyps by TAUS, and 90 overdiagnosed and 15 missed true polyps by EUS. There was no evidence of a difference between the diagnostic accuracy of TAUS and EUS (relative sensitivity 1.06, P = 0.70, relative specificity 1.15, P = 0.12).Differentiation between dysplastic polyps/carcinomas and adenomas/pseudo polyps of the gallbladder: Four studies (1,009 participants) used TAUS; the summary sensitivity was 0.79 (95% CI 0.62 to 0.90) and the summary specificity was 0.89 (95% CI 0.68 to 0.97). Three studies (351 participants) used EUS; the summary sensitivity was 0.86 (95% CI 0.76 to 0.92) and the summary specificity was 0.92 (95% CI 0.85 to 0.95). In a cohort of 1000 participants with gallbladder polyps, with 5% having a dysplastic polyp/carcinoma, this would result in 105 overdiagnosed and 11 missed dysplastic polyps/carcinomas by TAUS and 76 overdiagnosed and seven missed dysplastic polyps/carcinomas by EUS. There was no evidence of a difference between the diagnostic accuracy of TAUS and EUS (log likelihood test P = 0.74).

AUTHORS' CONCLUSIONS

Although TAUS seems quite good at discriminating between gallbladder polyps and no polyps, it is less accurate in detecting whether the polyp is a true or pseudo polyp and dysplastic polyp/carcinoma or adenoma/pseudo polyp. In practice, this would lead to both unnecessary surgeries for pseudo polyps and missed cases of true polyps, dysplastic polyps, and carcinomas. There was insufficient evidence that EUS is better compared to TAUS in differentiating between true and pseudo polyps and between dysplastic polyps/carcinomas and adenomas/pseudo polyps. The conclusions are based on heterogeneous studies with unclear criteria for diagnosis of the target conditions and studies at high or unclear risk of bias. Therefore, results should be interpreted with caution. Further studies of high methodological quality, with clearly stated criteria for diagnosis of gallbladder polyps, true polyps, and dysplastic polyps/carcinomas are needed to accurately determine diagnostic accuracy of EUS and TAUS.