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Size of gallbladder polyps (GP) is considered as a relevant risk factor for neoplastic polyps. However, the definitive impact is an ongoing debate. Current German and European guidelines recommend surveillance for GP > 6 mm and cholecystectomy for GP > 10 mm over a period of two to five years. We aimed to analyze the dynamic growth of gallbladder polyps. Patients at Hanover Medical School who underwent sonography from 2001 to 2020 were retrospectively evaluated for growth rate (GR) of detected GP independent of the underlying primary disease. Only patients with at least one follow-up as well as accurate GP size data were included in the study. A number of 253 patients with GP were eligible. Median follow-up was 66 months (24-209 months). Median GR was -0.3 mm/year (IQR 0.79). A subgroup analysis (polyp size 6-10 mm) showed a positive GR in 20.3% of the cases with a median GR of 0.09 mm/year (IQR 0.17). Of note, in 46% of the patients GP were not detectable at follow-up exam. Overall, two patients reached the indication for cholecystectomy (0.8%), whereas only a single patient developed histologically confirmed gallbladder cancer (0.4%). Logistic regression analysis did not reveal any risk factors associated with GP growth. The majority of GP, which should be monitored within the current follow-up strategy, are no longer detectable sonographically over time or show a decreasing growth behavior. Only a minority shows a very slow positive GR and only a minority of patients develop malignancy.

Incidentally detected gallbladder polyps (GBPs) and gallbladder wall thickening (GBWT) are frequently encountered in clinical practice. However, characterizing GBPs and GBWT in asymptomatic patients can be challenging and may result in overtreatment, including unnecessary follow-ups or surgeries. The Korean Society of Abdominal Radiology (KSAR) Clinical Practice Guideline Committee has developed expert recommendations that focus on standardized imaging interpretation and follow-up strategies for both GBPs and GBWT, with support from the Korean Society of Radiology and KSAR. These guidelines, which address 24 key questions, aim to standardize the approach for the interpretation of imaging findings, reporting, imaging-based workups, and surveillance of incidentally detected GBPs and GBWT. This recommendation promotes evidence-based practice, facilitates communication between radiologists and referring physicians, and reduces unnecessary interventions.

ObjectiveThe optimal management of acute cholecystitis in patients at very high risk for cholecystectomy is uncertain. The aim of the current study was to compare endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD) to percutaneous cholecystostomy (PT-GBD) as a definitive treatment in these patients under a randomised controlled trial.DesignConsecutive patients suffering from acute calculous cholecystitis but were at very high-risk for cholecystectomy were recruited. The primary outcome was the 1-year adverse events rate. Secondary outcomes include technical and clinical success, 30-day adverse events, pain scores, unplanned readmissions, re-interventions and mortalities.ResultsBetween August 2014 to February 2018, 80 patients were recruited. EUS-GBD significantly reduced 1 year adverse events (10 (25.6%) vs 31 (77.5%), p<0.001), 30-day adverse events (5 (12.8%) vs 19 (47.5%), p=0.010), re-interventions after 30 days (1/39 (2.6%) vs 12/40 (30%), p=0.001), number of unplanned readmissions (6/39 (15.4%) vs 20/40 (50%), p=0.002) and recurrent cholecystitis (1/39 (2.6%) vs 8/40 (20%), p=0.029). Postprocedural pain scores and analgesic requirements were also less (p=0.034). The technical success (97.4% vs 100%, p=0.494), clinical success (92.3% vs 92.5%, p=1) and 30-day mortality (7.7% vs 10%, p=1) were statistically similar. The predictor to recurrent acute cholecystitis was the performance of PT-GBD (OR (95% CI)=5.63 (1.20–53.90), p=0.027).ConclusionEUS-GBD improved outcomes as compared to PT-GBD in those patients that not candidates for cholecystectomy. EUS-GBD should be the procedure of choice provided that the expertise is available after a multi-disciplinary meeting. Further studies are required to determine the long-term efficacy.Trial registration number NCT02212717

ObjectivesTo assess important features for risk stratification of gallbladder (GB) polyps >10 mm using high-resolution ultrasonography (HRUS) and texture analysis.MethodsWe included 136 patients with GB polyps (>10 mm) who underwent both HRUS and cholecystectomy (non-neoplastic, n = 58; adenomatous, n = 32; and carcinoma, n = 46). Two radiologists retrospectively assessed HRUS findings and texture analysis. Multivariate analysis was performed to identify significant predictors for neoplastic polyps and carcinomas.ResultsSingle polyp (OR, 3.680–3.856) and larger size (OR, 1.450–1.477) were independently associated with neoplastic polyps (p < 0.05). In a single or polyp >14 mm, sensitivity for differentiating neoplastic from non-neoplastic polyps was 92.3%. To differentiate carcinoma from adenoma, sessile shape (OR, 9.485–41.257), larger size (OR, 1.267–1.303), higher skewness (OR, 6.382) and lower grey-level co-occurrence matrices (GLCM) contrast (OR, 0.963) were significant predictors (p < 0.05). In a polyp >22 mm or sessile, sensitivity for differentiating carcinomas from adenomas was 93.5–95.7%. If a polyp demonstrated at least one HRUS finding and at least one texture feature, the specificity for diagnosing carcinoma was increased to 90.6–93.8%.ConclusionIn a GB polyp >10 mm, single and diameter >14 mm were useful for predicting neoplastic polyps. In neoplastic polyps, sessile shape, diameter >22 mm, higher skewness and lower GLCM contrast were useful for predicting carcinoma.Key Points• Risk of neoplastic polyp is low in <14 mm and multiple polyps• A sessile polyp or >22 mm has increased risk for GB carcinomas• Higher skewness and lower GLCM contrast are predictors of GB carcinoma• HRUS is useful for risk stratification of GB polyps >1 cm

It is still challenging to make accurate diagnosis of biliary atresia (BA) with sonographic gallbladder images particularly in rural area without relevant expertise. To help diagnose BA based on sonographic gallbladder images, an ensembled deep learning model is developed. The model yields a patient-level sensitivity 93.1% and specificity 93.9% [with areas under the receiver operating characteristic curve of 0.956 (95% confidence interval: 0.928-0.977)] on the multi-center external validation dataset, superior to that of human experts. With the help of the model, the performances of human experts with various levels are improved. Moreover, the diagnosis based on smartphone photos of sonographic gallbladder images through a smartphone app and based on video sequences by the model still yields expert-level performances. The ensembled deep learning model in this study provides a solution to help radiologists improve the diagnosis of BA in various clinical application scenarios, particularly in rural and undeveloped regions with limited expertise. It is still challenging to make accurate diagnosis of biliary atresia (BA) with sonographic gallbladder images particularly in rural areas without relevant expertise. Here, the authors develop a diagnostic deep learning model which favourable performance in comparison with human experts in multi-center external validation.

ObjectivesWe evaluated the usefulness of real-time colour Doppler flow (CDF) endoscopic ultrasonography (EUS) for differentiating neoplastic gallbladder (GB) polyps from non-neoplastic polyps.MethodsBetween August 2014 and December 2016, a total of 233 patients with GB polyps who underwent real-time CDF-EUS were consecutively enrolled in this prospective study. CDF imaging was subjectively categorized for each patient as: strong CDF pattern, weak CDF pattern and no CDF pattern.ResultsOf the 233 patients, 115 underwent surgical resection. Of these, there were 90 cases of non-neoplastic GB polyps and 23 cases of neoplastic GB polyps. In a multivariate analysis, a strong CDF pattern was the most significant predictive factor for neoplastic polyps; sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 52.2 %, 79.4 %, 38.7 %, 86.9 % and 73.9 %, respectively. Solitary polyp and polyp size were associated with an increased risk of neoplasm.ConclusionsThe presence of a strong CDF pattern as well as solitary and larger polyps on EUS may be predictive of neoplastic GB polyps. As real-time CDF-EUS poses no danger to the patient and requires no additional equipment, it is likely to become a supplemental tool for the differential diagnosis of GB polyps.Key points• Differential diagnosis between neoplastic polyps and non-neoplastic polyps of GB is limited.• The use of real-time CDF-EUS was convenient, with high agreement between operators.• The real-time CDF-EUS is helpful in differential diagnosis of GB polyps.

Gallbladder wall thickening is relatively common in clinical settings, and for appropriate diagnosis, the size, shape, internal structure, surface contour, and vascularity of the gallbladder wall must be evaluated. Morphological evaluation is the most important; however, some gallbladder lesions resemble gallbladder cancer in imaging studies, making differential diagnosis challenging. Vascular evaluation is indispensable for a precise diagnosis in these cases. In this review, we present the current status of vascular evaluation using US and diagnosis using vascular imaging for gallbladder lesions, including those presenting with wall thickening. To date, several ultrasound imaging techniques have been developed to assess vascularity, including Doppler imaging with high sensitivity, use of contrast agents, and microvascular imaging using a novel filter for Doppler imaging. Although conventional color Doppler imaging is rarely used for the diagnosis of gallbladder lesions, the efficacy of contrast-enhanced ultrasound in assessing the vascularity, enhancement pattern, or timing of enhancement/washout has been reported. Presence of multiple irregular microvessels has been speculated to indicate malignancy. However, few reports on microvessels have been published, and further studies are required for the precise diagnosis of gallbladder lesions with microvascular evaluation.

Gallbladder polyps have a high prevalence and are predominantly benign lesions, often detected via ultrasound. They impose diagnostic burdens on radiologists while generating substantial patient demand for report interpretation. Benign polyps include nonneoplastic polyps without malignant potential and premalignant adenomas that require cholecystectomy. Current guidelines recommending surgery for polyps ≥1.0 cm may lead to unnecessary interventions. Advanced multimodal large language models (LLMs) such as ChatGPT-4o (OpenAI) and Claude 3.5 Sonnet (Anthropic PBC) demonstrate emerging capabilities in medical image analysis. Implementing LLMs in gallbladder polyp ultrasound evaluation can potentially alleviate radiologists' workload, provide patient-accessible consultation platforms, and even reduce overtreatment. We aimed to analyze the feasibility and conduct an early-stage evaluation of using LLMs for differentiating between adenomatous and nonneoplastic gallbladder polyps (≥1.0 cm) based on ChatGPT-4o and Claude 3.5 Sonnet, compared to assessments by radiologists and the guideline. Ultrasound images and reports of gallbladder polyps ≥1.0 cm with pathology were retrospectively collected from a hospital between January 2011 and January 2022. LLM performance was evaluated using three input strategies: (1) direct image analysis (LLMs-image), (2) feature-based text analysis (LLMs-text), and (3) scoring model-based text analysis (LLMs-model). Both intra- and interreader agreement and diagnostic performance of LLMs were evaluated for all three strategies. The diagnostic performance metrics-including sensitivity, specificity, accuracy, area under the receiver operating characteristic curve, and unnecessary resection rate of nonneoplastic polyps of LLMs in the three strategies were compared with the guideline. Additionally, the strategy LLMs-model was specifically compared with radiologists using the same scoring system (strategy readers-model). This study included 223 patients (aged 18-72 years; 132/223, 59.2% female) as the initial cohort, with 48 adenomatous polyps and 175 nonneoplastic polyps. The external test set comprised 100 patients. The intrareader agreement coefficients for strategy LLMs-model were significantly higher than those for strategy LLMs-image and LLMs-text (all P<.01). The interreader agreement of the three diagnostic strategies was ranked as LLMs-model>LLMs-text>LLMs-image. The sensitivity of strategies LLMs-image and LLMs-text was significantly lower than that of the guideline (all P<.001). When applying a scoring model (readers/LLMs-model strategy), both radiologists and the LLMs achieved a significantly higher accuracy compared to the guideline (0.34, 0.35, and 0.34 vs 0.22, all P<.01), and the unnecessary resection rate of nonneoplastic polyps was significantly lower (82%, 83%, and 83% vs 100%, all P<.01), while the sensitivity was comparable to the guideline (0.94, 0.98, and 0.98 vs 1.00, all P>.05). All diagnostic performance indicators for GPT-model and Claude-model were not significantly different from those of radiologists (all P>.05). The ability of LLMs to recognize and interpret medical images requires further improvement. The text strategy with a scoring system is currently the most appropriate diagnostic strategy for LLMs.

Abstract Background and Objective Studies in humans and mice have demonstrated that the gut hormone glucagon-like peptide 2 (GLP-2) promotes gallbladder relaxation and refilling. Here, we assessed the effect of exogenous GLP-2 on gallbladder motility in the fasted state of healthy men with and without infusion of the potent gallbladder-contracting hormone cholecystokinin (CCK). Methods In a randomized, double-blind, placebo-controlled, crossover study, 15 male participants (mean [SD]: age 24.7 [3.6] years; body mass index 22.9 [1.6] kg/m2) underwent 4 experimental days receiving 2 infusions on each day: either CCK (0.4 pmol × kg−1 × min−1, time 0-180 minutes) + GLP-2 (10 pmol × kg−1 × min−1, time 30-240 minutes), CCK + placebo, placebo + GLP-2, or placebo + placebo, respectively. Gallbladder volume was measured at baseline and throughout the 4-hour study day using ultrasonography. Results Compared to placebo + placebo, GLP-2 + placebo did not affect gallbladder volume, but when infused in combination with CCK, GLP-2 completely abolished the strong gallbladder-contracting effect seen during CCK + placebo infusion, restoring baseline levels of gallbladder volume. Conclusion Exogenous GLP-2 counteracts exogenous CCK-induced gallbladder emptying in healthy men, pointing to a possible therapeutic potential for GLP-2 as a relaxing modulator of gallbladder smooth muscle tone (eg, as a bridge to surgery in biliary colic). The effect may also explain the gallbladder-related adverse events reported for GLP-2 receptor agonists used in the treatment of short bowel syndrome. Clinical Trial Registration number NCT04651868

Cholecystectomy is indicated for gallbladder mucoceles (GBM). Evaluating the patency of the biliary duct and precise biliary tree visualization is crucial for reducing the risk of compromised bile flow after surgery. Therefore, intraoperative cholangiography (IOC) is recommended during cholecystectomy to prevent biliary tract injury. Although indocyanine green (ICG) cholangiography has been extensively reported in human medicine, only one study has been conducted in veterinary medicine. Therefore, this study aimed to demonstrate the use of ICG for IOC to identify fluorescent biliary tract images and determine the patency of the common bile duct during cholecystectomy in dogs. This study comprised 27 dogs, consisting of 17 with gallbladder mucoceles (GBM) and 10 controls, specifically including dogs that had undergone elective cholecystectomy for GBM. ICG injection (0.25 mg/kg) was administered intravenously at least 45 minutes before surgery. During the operation, fluorescent images from cholangiography were displayed on the monitor and obtained in black-and-white mode for the comparison of fluorescence intensity (FI). The FI values of the gallbladders (GBs) and common bile duct (CBD) were measured using FI analyzing software (MGViewer V1.1.1, MetapleBio Inc.). The results demonstrated successful CBD patency identification in all cases. Mobile GBM showed partial gallbladder visibility, whereas immobile GBM showed limited visibility. Additionally, insights into the adequate visualization of the remaining extrahepatic biliary tree anatomy were provided, extending beyond the assessment of CBD patency and gallbladder intensity. Our study demonstrates the potential of fluorescent IOC using intravenous injection of ICG for assessing the patency of the cystic duct and common bile duct during cholecystectomy in patients with GBM, eliminating the need for surgical catheterization and flushing of the biliary ducts. Further research is warranted to investigate and validate the broader applicability of ICG cholangiography in veterinary medicine.