Gallbladder polyps (GPs) have an estimated prevalence of approximately 0.3–12.3% [
1,
2], which varies widely in different regions of the world. They are rarely symptomatic [
3,
4] and are mainly incidental findings. Until recently it was generally assumed that polyps in the gallbladder have the potential to grow and become cancerous over many decades [
5]. However, a recent population-based study found out that the natural history of polyps is to grow over time, and polyps even more than 10 mm in size are rarely associated with gallbladder cancer (GBC; [
6]). The majority of GPs are classified as pseudo or cholesterol polyps. They have no malignant potential and, therefore, do not require follow-up or intervention. Past studies assumed that “true” GPs occur in 5% of cases [
1,
2,
7] and are subject to the adenoma–carcinoma sequence [
8]. Although rare, malignancy is significantly more common among polyps of 10 mm or greater in size [
2,
7]. It is therefore generally accepted that from this size up, GPs have to be removed surgically, preferably by laparoscopic cholecystectomy [
2,
9,
10]. Nevertheless, it remains uncertain how many polyps in the gallbladder ultimately progress and become cancerous. The aforementioned recently published study involving more than 600,000 patients reported a very low incidence of GBC in GP carriers, which was interestingly comparable to patients without GPs [
6].
This review discusses recent findings on the central role of imaging in diagnosis and discrimination between “true” and pseudo polyps and their treatment. Given the low incidence of true polyps, the decision for laparoscopic cholecystectomy must be balanced against its postoperative morbidity, which is moderate but severe when bile duct injuries occur. The recommendations of recent guidelines are not uniform and rely on a low level of evidence due to the small numbers, short follow-up, and current data not being taken into account in the referenced studies. The white paper of the American College of Radiology, for example, recommends yearly follow-up for polyps sized 7–9 mm and consultation for cholecystectomy in the case of a polyp growth [
9]. The American Society for Gastrointestinal Endoscopy also recommends indefinite yearly monitoring for GPs [
11], and a joint guideline from various European societies recommended surgery for all polyps larger than 10 mm and those larger than 6 mm with risk factors as well as 5 years of follow-up for all other polyps [
10]. In view of recent findings, there appears to be a need for a revision of existing guidelines, in particular concerning periodic ultrasonography of GPs to detect GBC proactively.