patients with signs of vascular injury had injury confirmed by angiography. Using angiography as the gold standard in the 59 patients, the overall sensitivity of physical examination to detect vascular injury in stable patients with gunshot wounds to the neck was 57%. Specificity was 53%, with positive and negative predictive values of 43% and 66%.Comment: In recent years, there has been a trend towards more conservative use of catheter-based angiography in patients with possible vascular injury. This trend has been most marked in the evaluation of patients with posterior knee dislocation and in the evaluation of stable patients with penetrating trauma to an extremity. The current data, however, suggest that hemodynamically stable patients with gunshot wounds to the neck should still undergo routine imaging evaluation. In some centers, this may be duplex scanning or computed tomography angiography rather than a catheter-based angiogram. Aortic calcification and the risk of osteoporosis and fractures

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Gallstone ileus is a rare cause of mechanical intestinal obstruction accounting for less than 1% of obstructions and results from the migration and impaction of a gallstone within the gastrointestinal tract. It is a rare complication of cholelithiasis seen in as little as 0.3% of patients. Morbidity associated with gallstone ileus has been reported as up to 27% and mortality rate has been reported at rates ranging from 7% to 30%, this is attributed to advanced age, and delay to presentation at treatment. An 86-year old male who presented to a rural hospital with signs and symptoms consistent with small bowel obstruction and imaging demonstrating features consistent with gallstone ileus. Diagnosis was made on computed tomography (CT) of a small bowel obstruction secondary to a large impacted gallstone. Our case highlights the ongoing utility and diagnostic value of abdominal X-ray, particularly in rural facilities with limited resources. The case also highlighted the approach of laparoscopic assisted removal of gallstone alone in medically comorbid patients, in rural facilities and particularly in the elderly population who may not be fit for longer initial surgical procedures or subsequent procedures to close choledochoduodenal fistula.

Conclusion: NOM is the standard of care for blunt hepatic and splenic injury and successful in >80% of patients. The presented clinical algorithm is primarily guided by clinical parameters and is safe with a low mortality rate <2%.