The case of a 67-year-old male patient affected by ingravescent obstructive jaundice, calcific choledocholithiasis and cardiopathic hypertension, is presented. On sonography, marked dilatation of intra- and extrahepatic bile ducts with a hyperechoic round neoformation was visualized. CT was performed to ascertain the nature of the lesion. However, it did not confirm the lithiasic nature of the stenosis. Sampling for ERCP was inadequate. Cholangiopancreatography was therefore necessary to establish a correct diagnosis and the subsequent therapeutic approach. Distal choledochal obstruction was evidenced, suspicious for lithiasis obstruction. A definitive diagnosis could not be established on exclusive imaging findings. Surgery was performed with the diagnosis of cholangiocarcinoma with lithiasis.