Beyond the Usual Suspect: Diagnostic Pitfalls and Uncommon Presentations of Acute Appendicitis – A Case Series

Acute appendicitis is traditionally regarded as one of the most common and straightforward indications for emergency abdominal surgery. Nevertheless, its heterogeneous clinical presentations can mimic other intra-abdominal conditions or co-occur with pathologies such as intestinal obstruction, peptic ulcer perforation, and pancreatitis. These complex presentations often present diagnostic hurdles, highlight the limitations of conventional imaging, and underscore the imperative for careful clinical acumen. We report a case series of five patients, all of whom were initially suspected to have acute appendicitis. However, their subsequent clinical course and operative findings revealed a variety of diagnostic pitfalls: caecal perforation at the base of the appendix, coexistent acute pancreatitis, retrocecal appendix obscured on ultrasound, a sealed gastric perforation masquerading as appendicitis, and acute intestinal obstruction rooted in adhesions around an inflamed appendix. Each scenario demanded a distinct management strategy, ranging from hemicolectomy and stoma formation to conservative treatment of pancreatitis and meticulous operative exploration of retrocecal anatomy. These cases exemplify the dynamic nature of acute appendicitis and call attention to the importance of a broad differential diagnosis. They further illustrate that clinical vigilance, paired with thoughtful imaging and operative nuance, is indispensable for optimizing patient outcomes.