The majority of ingested foreign bodies (FBs) pass through the GI tract uneventfully [
4]. Fish bones commonly perforate sites with acute angulations such as the ileocecal junction or the flexures of the colon [
5]. They may rarely perforate the appendix or a Meckel’s diverticulum [
3]. Ileal perforation can result in abscess formation and commonly presents with right iliac fossa pain mimicking acute appendicitis. This patient presented with features of acute appendicitis with mass formation. The clinical, biochemical and ultrasonic findings were favoring the diagnosis of appendicitis. A computed tomography (CT) scan was not performed as it is not a routine investigation in appendicitis. In a majority of previous cases, reported CT scans were performed as a supportive investigation although the sensitivity of CT scans in detecting a fish bone is low [
6]. A perforation when detected by CT scan can appear as a segmental intestinal wall thickening, localized pneumoperitoneum, localized fatty infiltration, or associated intestinal obstruction. However, none of these findings is specific, and the definitive diagnosis is made by identification of the calcified FB [
6]. The visualization of fish bones depends on the degree of calcification and varies with the species of fish [
7]. Perera
et al. have reported a case of fish bone migration to the liver diagnosed with typical ultrasonic features [
8]. This phenomenon occurs when the bone perforates the hepatic flexure. Most of the previously reported cases were managed operatively with resection of small bowel and anastomosis [
9,
10]. This patient could be managed expectantly as the perforation was already partially sealed off by omentum and fibrinous exudate. An attempt was not made to apply a stitch to the site as the suture would have cut through inflamed tissue and the omental cover would have be disturbed in the process. The peritoneal cavity did not have gross contamination by intestinal content in this patient. This is a well-recognized feature of perforations caused by fish bones as the perforation is caused by impaction and progressive erosion of the FB through the intestinal wall. This also limits the passage of large amounts of intraluminal air into the peritoneal cavity making it difficult to be detected in radiography [
5]. The increasing use of laparoscopy for appendicectomy and as a tool for initial exploration of abdominal sepsis has helped in diagnosing this type of rare condition, preventing the morbidity of a laparotomy for patients [
11]. This patient was able to be treated nonsurgically as the cause for his symptoms and the extent of sepsis could be accurately ascertained with laparoscopy.