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Acute pain in right iliac fossa is a common complaint in surgical practice. It is a common symptom of acute appendicitis, which is a surgical emergency. We present an interesting case of an elderly male with acute pain in right iliac fossa mimicking appendicitis but cause found to be a fish bone perforating terminal ileum. Rare causes of pain in the right iliac fossa mimicking appendicitis were reviewed, which surgeons need to be aware of.