On ultrasound, a gallbladder polyp is most likely malignant when:

• A Multiple, sessile, hyperechoic, with posterior acoustic shadowing
• B Solitary, sessile, >10 mm, with internal vascularity on Doppler ✓
• C Pedunculated, mobile, <5 mm, multiple in number
• D Associated with gallstones without wall thickening

Explanation

Malignant potential in gallbladder polyps is highest when the polyp is: solitary (rather than multiple), sessile (flat, broad base), ≥10 mm in size, and shows internal vascularity on Doppler. These features warrant cholecystectomy. Small (<5 mm), multiple, pedunculated polyps are almost always cholesterol polyps (benign). Posterior acoustic shadowing suggests gallstones, not polyps. Size ≥10 mm is the most important criterion; some guidelines use 6 mm in high-risk patients (PSC, Indian ethnicity). The combination of size, vascularity, and sessile morphology defines the highest-risk polyp profile.

Reference: Grainger & Allison's Diagnostic Radiology, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.