Diagnostic performance of imaging techniques in choledocholithiasis: Accuracy, predictive values, and limitations of magnetic resonance cholangiography

Abstract

Introduction: Choledocholithiasis is a highly prevalent condition in Chile, and its diagnosis is based on the integration of clinical, biochemical, and imaging criteria. Multiple imaging techniques and approaches are available, which differ in accuracy and availability. Objective: To describe the diagnostic limitations of the available imaging techniques based on a clinical case, and to analyze the accuracy, predictive values, and key limitations of each modality according to the published literature. Methodology: A clinical case is described and the medical implications are analysed based on a review of recent literature on the subject. Result: Magnetic resonance cholangiopancreatography may present false negatives in 5-12% of cases, especially with stones <6 mm, biliary sludge, or distal lithiasis. Endoscopic ultrasound offers greater sensitivity (93-97%), while intraoperative cholangiography reaches values close to 99%, making it a key tool for intraoperative detection of previously unsuspected stones. Discussion: This case highlights the importance of critically interpreting imaging findings and not excluding choledocholithiasis solely based on a negative magnetic resonance cholangiopancreatography in patients with high clinical suspicion. The literature supports the utility of endoscopic ultrasound and intraoperative cholangiography as complementary methods. Conclusion: Magnetic resonance cholangiopancreatography is a very useful tool but not free from limitations. In scenarios of high suspicion, more sensitive techniques such as endoscopic ultrasound or intraoperative cholangiography should be considered.