What is the preferred initial imaging modality for suspected gallstones?

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Abdominal ultrasound is the best initial imaging because it directly visualizes the gallbladder and stones without radiation, is fast and widely available, and has high sensitivity for detecting gallstones. Stones appear as bright echoes with posterior acoustic shadowing, and ultrasound can also assess for signs of inflammation such as gallbladder wall thickening or pericholecystic fluid, which helps distinguish cholecystitis. If ultrasound is nondiagnostic or ductal stones are suspected, further imaging like MRCP or endoscopic ultrasound can be used, but they are not first-line due to cost, invasiveness, and access. CT is less sensitive for stones and is typically reserved for other abdominal problems or complications.