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SRU 2022 gallbladder polyp calculator

For incidentally detected gallbladder polyps on ultrasound in adults, per the Society of Radiologists in Ultrasound 2022 consensus. Pick the morphology, enter the size of the largest polyp, and the calculator resolves the tier and the recommendation. Not for patients with primary sclerosing cholangitis, or for lesions with features of gallbladder cancer.

Polyp morphology (describe it in the report) Pedunculated, thin stalk — Narrow stalk — may need Doppler/microflow or mobility to show it. Ball-on-the-wall — Round polyp resting on the wall with a narrow point of contact. Pedunculated, thick/wide stalk — Pedunculated but on a broad stalk. Sessile (broad-based) — Flat or dome-shaped, no stalk. Uncertain / not described — SRU 2022 defaults to the low-risk tier when morphology is unclear.

Adjacent wall Focal wall thickening ≥4 mm adjacent to the polyp — not attributable to wall edema, mucosal folds, adenomyomatosis or gallbladder under-distension (indeterminate tier, overrides the stalk)

Size of the largest polyp (mm) rounded to the nearest millimetre; the number of polyps does not change the tier

Prior study (optional — growth rules)

Context Primary sclerosing cholangitis — outside the SRU 2022 algorithm Known geographic / genetic gallbladder-cancer risk — optional: raises an extremely-low-risk polyp to low risk, no further

The SRU 2022 management table

Size is the largest polyp, rounded to the nearest millimetre. The radiologist recommends surgical consultation — the consensus recommends consultation rather than cholecystectomy, because the operative decision is the surgeon's.

Risk tier	Largest polyp	Recommendation
Extremely low risk	≤9 mm	No follow-up
Extremely low risk	10-14 mm	Follow-up ultrasound at 6, 12 and 24 months; surgical consultation is an acceptable alternative depending on patient factors
Extremely low risk	≥15 mm	Surgical consultation
Low risk	≤6 mm	No follow-up
Low risk	7-9 mm	One follow-up ultrasound at 12 months
Low risk	10-14 mm	Follow-up ultrasound at 6, 12, 24 and 36 months, or surgical consultation
Low risk	≥15 mm	Surgical consultation
Indeterminate risk	≤6 mm	Follow-up ultrasound at 6, 12, 24 and 36 months, or surgical consultation
Indeterminate risk	≥7 mm	Surgical consultation

How the tiers are defined

By polyp morphology only — not by patient age, vascularity, multiplicity or gallstones.

Tier	Definition	Features
Extremely low risk	Pedunculated with a thin stalk, or a "ball-on-the-wall" configuration.	Thin-stalk pedunculated polyp "Ball-on-the-wall": a round polyp sitting on the mucosa with only a narrow point of contact A thin stalk can be invisible on grayscale — Doppler/microflow imaging or demonstrating mobility can show it
Low risk	Sessile (broad-based), or pedunculated with a thick/wide stalk. Use this tier when the morphology is uncertain or not described.	Sessile / broad-based polyp Pedunculated polyp with a thick or wide stalk Morphology uncertain or not described
Indeterminate risk	Focal gallbladder wall thickening ≥4 mm adjacent to the polyp that cannot be attributed to wall edema, mucosal folds, adenomyomatosis or gallbladder under-distension.	Adjacent focal wall thickening ≥4 mm Overrides the stalk morphology — a thin-stalk polyp with adjacent wall thickening is indeterminate, not extremely low

Growth and when follow-up stops

Finding on follow-up	Rule
Rapid growth	An increase of ≥4 mm within 12 months → surgical consultation.
Reaches the consultation size	A polyp that grows to its tier's surgical-consultation size (≥15 mm extremely-low/low risk; ≥7 mm indeterminate) → surgical consultation.
Decrease	A decrease of ≥4 mm → no further follow-up.
Stable	Growth under 4 mm does not by itself change management. Follow-up stops at the end of the tier's schedule (12, 24 or 36 months; 36 months at most) if the polyp is stable.

What does not change the tier

Factor	SRU 2022
Patient age	Not a tier modifier in SRU 2022 (it is in the European guideline).
Doppler vascularity	Internal flow, present or absent, does not change the tier — it may help show a thin stalk, nothing more.
Number of polyps	Manage by the largest polyp; multiplicity does not change the tier.
Coexisting gallstones	Do not change the tier.
Geographic / genetic risk	Known high gallbladder-cancer risk (e.g. North Indian, Indigenous American, high local incidence) MAY optionally raise an extremely-low-risk polyp to low risk — no further.

Not covered by this algorithm

Situation	Why
Primary sclerosing cholangitis	Increased malignancy risk — manage under gastroenterology/hepatology guidance, not this algorithm.
Features of gallbladder cancer	Wall invasion, liver infiltration or adenopathy take the lesion out of the incidental pathway — specialist referral.
Adenomyomatosis	Comet-tail / twinkling artifact from intramural cholesterol crystals is not a polyp.
Cholesterolosis without a discrete polyp	Not a polypoid lesion — the algorithm does not apply.

SRU 2022 vs the European guideline

The 2017 ESGAR/EAES/EFISDS/ESGE joint guideline (Wiles R, et al. Eur Radiol 2017;27(9):3856-3866) and its 2022 update (Foley KG, et al. Eur Radiol 2022;32:3358-3368) are a different algorithm. If a report cites “SRU 2022” but uses any of the rules in the left-hand column, it is quoting the European guideline.

Point	European rule vs SRU rule
Cholecystectomy threshold	European 2017/2022: cholecystectomy advised at ≥10 mm, and for 6-9 mm polyps with a risk factor. SRU 2022: surgical consultation at ≥15 mm (extremely-low/low risk) or ≥7 mm (indeterminate); 10-14 mm is follow-up or consultation.
Risk factors	European: patient-level factors (age >50 in 2017, >60 in the 2022 update; Asian ethnicity, PSC, sessile morphology / focal wall thickening >4 mm). SRU: morphology only; PSC is outside scope; age and ethnicity do not change the tier.
Growth	European: growth ≥2 mm is significant. SRU: ≥4 mm within 12 months.
Follow-up duration	European: 5 years (2017), shortened to 2 years (2022). SRU: stops at 36 months if stable.

Bosniak 2019 renal cyst classification — another incidental-lesion algorithm
LI-RADS calculator — hepatobiliary imaging
All radiology calculators

Source. Kamaya A, et al. Radiology 2022;305(2):277-289. View on PubMed

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This is a reference implementation of a published guideline, for use by qualified clinicians. It does not account for patient-specific factors and is not a substitute for clinical judgment or a formal radiology consultation. See our full disclaimer.