the appendix is an out - pouching from the caecum , and is often called the abdominal tonsil due to the presence of lymphoid follicles . the appendix is usually present singlely with the base located at the convergence of taeniae along inferior aspect of the ceacum while its tip lies at various locations . appendiceal anomalies although rare include agenesis , duplication , triplication and anomalously located solitary appendix . about 8% of western population have inflammation of appendix during their lifetime , this makes acute appendicitis the most common general surgical emergency . acute appendicitis can present in a various manners , one rare form being small bowel obstruction . we are reporting a unique case of acute appendicitis having appendiceal duplication , presenting as small bowel obstruction . a 40 year old male was admitted to our emergency department as a case of pain in the abdomen for 6 days . patient had no history of prior abdominal surgery , loss of weight , bleeding with stools or intake of any medication . past medical and surgical histories were unremarkable . on examination , he was found to have a blood pressure of 120/80 , pulse rate of 106 beats / min , and had a temperature of 101 f. abdominal examination revealed abdominal distension , lower abdominal guarding more so in the right iliac fossa with rebound tenderness and increased bowel sounds . his abdominal ultrasonography scans revealed multiple dilated loops of small bowel with free fluid in pelvis and paracaecally . because of the uncertinity of the diagnosis an exploratory laparotomy was performed through a right paramedian incision under emergency settings . surprisingly two ceacal appendices were noted , the tip of one was pre - ileal having gross inflammation with its base on the anterior most tenia coli and the tip across the terminal most part of cecum with multiple adhesions kinking the bowel . the tip of the other appendix was retrocaecal having a perforation in the middle third with its base at the confluence of the tenia . about 200ml of foul smelling frank pus was present in the paracaecal recess and pelvis . intra - operative picture of two inflamed appendices intra - operative picture of two inflamed appendices the adhesiolysis and appendectomies were duly done and generous isotonic saline washes were performed . the patients post operative period was uneventful and he was discharged after 4 days of hospital stay . the histopathology analysis revealed acute appendicitis for the pre - ileal appendix and gangrene of the retroceacal appendix . appendiceal anomalies have been reported on numerous occasions . these include agenesis , duplication , triplication , anomalously located solitary appendix and the more recently described horseshoe appendix(1 ) . they are thought to result due to the persistence of normally transient embryologic second caecal appendix . less than 100 cases of appendiceal duplication in which two appendices are present have been reported(3 ) . a single case of appendiceal triplication has been reported till now along with a 0.004% incidence of appendiceal duplication(4 ) , thereby concluding that appendiceal anomalies are rare . cave in 1936 devised the first system classifying appendiceal duplication(5 ) . later on it biermann in 1993(7 ) proposed the following classification type b and c can have associated genitourinary and gastrointestinal anomalies.(8 ) acute appendicitis is also known to be a rare cause of mechanical small bowel obstruction(9 ) , usually resulting from adhesions due to periappendicular inflammation and is different from ileus seen in patients having perforated appendicitis presenting with generalized or localized peritonitis . inspite of previous reports , such a presentation of acute appendicitis is not recognized widely , which may cause delays in diagnosis and management . thereby resulting in an increased chance of post operative and long term complications . harris et al ( 10 ) in a series of 10 cases of appendicitis with gangrene , necrosis or perforation reported that the most common cause of the mechanical bowel obstruction was an appendix that lay across the terminal ileum with adhesive bands holding it down . he concluded that very often the differentiation between adynamic ileus and true mechanical obstruction is difficult to elicit clinically .
acute appendicitis , as well as intestinal obstruction , is a common surgical emergencies . both the conditions can present as an acute abdomen , however the diagnosis of acute appendicitis can be overlooked when it presents as a small bowel obstruction . 
 difficulties in correctly identifying the cause of pain can be hazardous to the patient and care needs to be taken in obtaining a prompt and accurate diagnosis enabling the most appropriate management . 
 appendiceal duplication although rare and difficult to diagnose preoperatively , should be checked while operating for appendicular pathology in order to avoid serious clinical and medicolegal implications.we hereby report a case of appendiceal duplication presenting as small bowel obstruction with one appendix having acute appendicitis and the other one perforated in the middle third .