Diagnostic Performance of Magnetic Resonance Cholangiopancreatography, Endoscopic Ultrasound, Endoscopic Retrograde Cholangiopancreatography, and Computed Tomography in Biliary Tract Pathologies: A Systematic Review and Comparative Analysis

Biliary tract disease is challenging to diagnose, as the anatomy is complex and complications arise. Various imaging modalities are available with differential benefits and limitations in detecting choledocholithiasis, strictures, and malignancy. This systematic review aimed to comprehensively assess and compare the diagnostic performance, clinical significance, and safety of magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), computed tomography (CT), and endoscopic ultrasonography (EUS) in evaluating biliary tract disease. Thirty studies that compared at least two radiological modalities were selected and reviewed. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies 2, and evidence quality was graded using the Grading of Recommendations Assessment, Development and Evaluation framework. MRCP demonstrated median sensitivity and specificity of 88.5% (interquartile range [IQR] 82.1%–94.8%; range 37.5%–97.4%) and 95.7% (IQR 93.9%–96.0%; range 83.8%–100.0%), respectively, for choledocholithiasis detection. EUS exhibited superior performance with a median sensitivity of 94.8% (IQR 90.2%–97.4%; range 80.0%–100.0%) and specificity of 98.5% (IQR 97.3%–100.0%; range 95.0%–100.0%). For biliary strictures, MRCP, EUS, ERCP, and CT demonstrated median sensitivity/specificity of 83.3%/76.0%, 67.0%/79.0%, 85.0%/75.0%, and 72.0%/72.5%, respectively. Corresponding values for malignancy differentiation were 81.0%/88.9%, 71.0%/78.5%, 81.4%/80.7%, and 72.0%/72.5%, respectively. Our analysis has revealed specific diagnostic niches for each imaging modality. MRCP is generally preferred for initial imaging evaluation, whereas EUS provides higher sensitivity for stone detection and enables tissue acquisition if required. ERCP is preferred when therapeutic intervention is required and to diagnose complex strictures. CT is most appropriate for selected obstructive and malignant biliary conditions. The evidence favors a stratified, condition‐specific algorithm rather than a universal one.