Background: Neonatal and infantile cholelithiasis is an uncommon condition, increasingly recognized due to widespread use of ultrasonography. Although most cases are asymptomatic and self-limiting, gallstones in neonates may present with feeding intolerance, cholestasis, or hyperbilirubinemia. Case Presentation: We report a preterm male twin born at 31 weeks and 2 days of gestation via lower segment cesarean section (LSCS), admitted to the neonatal intensive care unit (NICU) for respiratory distress. On day 3 of life, twin 2 developed feeding intolerance, abdominal distension, and neonatal hyperbilirubinemia. Abdominal ultrasonography revealed cholelithiasis with gallbladder sludge. Hyperbilirubinemia was managed with one day of phototherapy, resulting in normalization of serum bilirubin levels appropriate for gestational age and day of life. Conservative management was adopted, and the infant showed clinical improvement without surgical intervention. Conclusion: Neonatal cholelithiasis in preterm infants may be associated with prematurity and phototherapy exposure. Most cases resolve spontaneously with conservative management. Awareness of this entity is important to avoid unnecessary invasive interventions.